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A TREATISE 



DISEASES OF THE EYE. 



BY 

J. SOELBEKG WELLS, F.E.O.S., 

DOCTOR OP MEDICINE OF THE UNIVERSITY OF EDINBURGH ; PROFESSOR OF OPHTHAL- 
MOLOGY IN KING'S COLLEGE, LONDON; OPHTHALMIC SURGEON TO KING'S 
COLLEGE HOSPITAL; AND SURGEON TO THE ROYAL LONDON 
OPHTHALMIC HOSPITAL, MOORFIELDS. 



SECOND AMERICAN, 

FROM THE 

THIRD ENGLISH EDITION, WITH ADDITIONS. 

ILLUSTRATED WITH 

®ino ?Huit&"iJ anir jFartj-ttjsijt 35njjra6tnjj« an 8Stoou anir Six ©oloreir plates. 

TOGETHER WITH 
SELECTIONS FEOM THE TEST-TYPES OP PROP. E. JAEGER AND DR. H. SNELLEN. 




PHILADELPHIA: 

HENKY O. LEA 
1873. 



Entered according to the Act of Congress, in the year 1873, by 

HENRY C. LEA, 
in the Office of the Librarian of Congress. All rights reserved. 




fto' \ 

/6f3 



Philadelphia: 

collins, _pri ntei 

705 Jayne Street. 



AMERICAN PUBLISHER'S ADVERTISEMENT. 



The marked success of this work in England and America, as 
shown in the demand for successive editions, and its translation 
into both French and German, are sufficient evidence that it has 
supplied a want generally felt by the profession of a complete but 
compendious view of modern ophthalmology. As before, the 
present edition has been superintended by Dr. I. Minis Hays, who 
has introduced a considerable number of illustrations, and has 
added selections from the test-types of Jaeger and of Snellen, both 
of which are referred to in the text, and are recommended for use 
by the author. He has, likewise, inserted a few notes, though the 
very recent appearance of the third English edition has left little 
of novelty which had not received the attention of the author. 
His additions will be found distinguished by inclosure in brackets. 

A portion of the sheets of the present edition had already been 
printed, prior to the publication of the new English edition. Of 
this portion the additions and alterations will be found grouped 
together in the appendix. 

Philadelphia, Oct. 1873. 



PREFACE TO THE SECOND EDITION. 



It has afforded me no small gratification that the first edition 
of this work should have met with so very favorable a reception, 
both by the profession at large, and by the British and Foreign 
Medical Press ; and especially that it should have been deemed 
worthy of being translated into French and German, in both of 
which languages it will be published in the course of this year. 

Stimulated by such encouragement, I have endeavored to render 
the second edition as complete as possible, and have made numer- 
ous additions, incorporating all the important facts elucidated by 
the most recent researches, so that the work might be brought up 
to the latest date. 

16, Sayille Row, May, 1870. 



PREFACE TO THE FIRST EDITION. 



"Within the last few years the want has often been expressed of 
an English treatise on the diseases of the eye, which should embrace 
the modern doctrines and practice of the British and Foreign 
Schools' of Ophthalmology, and should thus enable the practitioner 
and student to keep up with the knowledge and opinions of the 
present day. 

I now venture to lay before the Profession a work which I trust 
may be deemed, to a certain extent, worthy to meet this desider- 
atum. Whilst I have endeavored to enter fully into all the most 
important advances which have been lately made in Ophthalmic 
science, I have not contented myself with simply recording the 
views of others, but have sought in most instances to make myself 
practically conversant with them, so that I might be able, from my 
own experience, to form an independent and unbiassed opinion as 
to their relative value. The vast and peculiarly favorable oppor- 
tunities which I have had at Moorfields of studying all phases and 
kinds of eye-disease, as well as the great benefit which I have 
enjoyed of witnessing the practice and operations of my colleagues, 
have most materially assisted me in the possibility of doing this. 

In preparing this work, I have steadily kept one purpose in 
view, viz., to make it as practical and comprehensive as possible, 
and I have, therefore, entered at length into an explanation of 
those subjects which I have found to be particularly difficult to 
the beginner. I have, on purpose, occasionally repeated important 
points in diagnosis and treatment, in order to render each article, 
to a certain extent, complete in itself, so as to obviate the necessity 
of the reader having constantly to refer to other portions of the 
book for explanation or information. Moreover, I have thought 
that this would prove of great convenience to those who may desire 
to consult and study certain subjects, without being obliged to 
peruse the greater portion of the book. 

The subjects of "Injuries to the Eye," and of "Congenital Mal- 
formations of the Eye," have assumed such considerable dimensions, 



Vlll PREFACE. 

that I have been obliged to treat of them somewhat briefly, and 
would, therefore, refer the reader, who seeks for fuller information, 
to special treatises upon these affections. Of these, I would par- 
ticularly recommend the following excellent works: "Injuries of 
the Eye, Orbit, and Eyelids," by Mr. George Lawson ; " Verletzun- 
gen des Auges," by Drs. Zander and Geissler; and the "Malforma- 
tions and Congenital Diseases of the Organs of Sight," by Sir 
"William Wilde. 

My best and warmest thanks are due to my colleagues at the 
Eoyal London Ophthalmic Hospital, Moorfields, and more especially 
to Mr. Bowman, for their constant kindness in permitting me to 
have free access' to their cases, and for affording me much valuable 
information and advice upon all subjects connected with Ophthal- 
mology. 

Owing to the great liberality of my friend Dr. Liebreich, and of 
his publisher. Mr. Hirsehwald of Berlin, I have been able to illus- 
trate this work with 16 excellent colored ophthalmoscopic figures, 
which are copies of some of the plates of Liebreich's admirable 
"Atlas d'Ophthalmoscopie." 

As very frequent reference is made to certain Ophthalmic peri- 
odicals, I have used the following abbreviations : — 

It. L. 0. H. Rep. signifies " Royal London Ophthalmic Hospital 
Reports," edited by Messrs. Wordsworth and Hutchinson (Church- 
ill). 

A. f. 0. signifies " Archiv fur Ophthalmologie," edited by Profs. 
Arlt, Donders, and Von Graefe (Peters, Berlin). 

Kl. Monatsbl. signifies " Klinische Monatsblatter der Augenheil- 
kunde," edited by Prof. Zehender (Enke, Erlangen). 

The following symbols are also frequently employed in the course 

of the work: — , means range of accommodation; r, punctum 

remotissimum (far point); p, punctum proximum (near point); 
oo (= 0), infinite distance; ', foot, ", inch, '", line. 

The test-types of Jaeger may be obtained from the Secretary of 
the Royal London Ophthalmic Hospital, Moorfields, and those of 
Snellen from Messrs. Williams and Norgate, Henrietta Street, Co- 
vent Garden. 

16, Saville Row, 

December, 1868. 



CONTENTS, 



Introduction. 

PAGE 

E version of the Upper Eyelid — The mode of ascertaining the degree of 
Intra-ocular Tension — The examination of the Acuteness of Vision — 
Mode of examining the Field of Vision — Diplopia — The Compress 
Bandage— The Artificial Leech— The Eye-douche .... 17-32 

Chapter I. 

DISEASES OP THE CONJUNCTIVA. 

Hypersemia of the Conjunctiva — Catarrhal Ophthalmia — Purulent Ophthal- 
mia — Gonorrhceal Ophthalmia — Ophthalmia Neonatorum — Diph- 
theritic Conjunctivitis — Granular Ophthalmia — Acute Granular 
Ophthalmia — Chronic Granulations — Phlyctenular Ophthalmia — 
Exanthematous Ophthalmia — Xerophthalmia — Pterygium — Symble- 
pliaron — Ankyloblepharon — Injuries of the Conjunctiva — Tumors 
of the Conjunctiva, etc 33-107 

Chapter II. 

DISEASES OP THE CORNEA. 

Pannus — Phlyctenular Oorneitis — Fascicular Corneitis— Suppurative Cor- 
neitis — Non-Inflammatory Suppurative Corneitis — Ulcers of the 
Cornea — Diffuse Corneitis — Opacities of the Cornea — Arcus Senilis — ■ 
Conical Cornea — Kerato-globus — Staphyloma of the Cornea and Iris 
— Injuries and Wounds of the Cornea 108-164 

Chapter III. 

DISEASES OF THE IRIS. 

Hypersemia of the Iris — Inflammation of the Iris — Functional Disturb- 
ances of the Iris — Tremulousness of the Iris — "Wounds, etc., of the 
Iris — Tumors of the Iris — Congenital Anomalies of the Iris — Iridec- 
tomy — Iridodesis — Corelysis — Iridodialysis — Changes in the contents, 
etc., of the Anterior Chamber — Irido-choroiditis — Sympathetic Oph- 
thalmia 165-327 



X CONTENTS. 

Chapter IV. 
DISEASES OP THE CILIARY BODY AND SCLEROTIC. 

PAGE 

Inflammation of Ciliary Body— Injuries of Ciliary Region— Episcleritis— 

Anterior Sclerotic Staphyloma— Wounds and Injuries of the Sclerotic 228-237 

Chapter V. 

DISEASES OF THE CRYSTALLINE LENS. 

Cataract — Lamellar Cataract — Cortical Cataract — Nuclear Cataract — 
Traumatic Cataract — Capsular Cataract — Flap Extraction — Removal 
of the Lens in its Capsule — Linear Extraction — Scoop Extraction — 
Von Graefe's Operation, etc.' — Reclination — Division of Cataract — 
Operations for Lamellar Cataract — Operations for Traumatic Cataract 
— Removal of Cataract by a Suction Instrument — Sperino's Treatment 
of Cataract by Paracentesis — Operations for Capsular Cataract — 
Dislocation of the Lens 238-311 

Chapter VI. 

THE USE OF THE OPHTHALMOSCOPE. 

Theory of the use of the Ophthalmoscope — Ophthalmoscope of Liebreich, 
Coccius, Zehender [and Loring] — Fixed Ophthalmoscope of Liebreich 
— Binocular Ophthalmoscope of Giraud-Teulon — Aut-ophthalmoscope 
— The Examination with the Ophthalmoscope — The Examination of 
the Actual Inverted Image — The Examination of the Virtual Erect 
Image — The Ophthalmoscopic Appearances of Healthy Eyes — The 
Optic Disk — -The Ophthalmoscopic Appearances of Diseased Eyes . 312-344 

Chapter VII. 

DISEASES OF THE VITREOUS HUMOR. 

Inflammation of the Vitreous Humor — Opacities — Foreign Bodies, etc., in 

the Vitreous — Persistent Hyaloid Artery 345-359 

Chapter VIII. 
DISEASES OF THE RETINA. 

Hyperemia of the Retina — Retinitis, Idiopathic and Parenchymatous — 
Retinitis Albuminurica, Lucsemica, Syphilitica, Apoplectica, Pigmen- 
tosa — Detachment of the Retina — Epilepsy of the Retina — IschaBmia 
Retinae — Embolism of the Central Artery of the Retina — Hyperes- 
thesia of the Retina — Tumors of the Retina — Atrophy of the Retina 
— Cysts in the Retina 360-408 



CONTENTS. XI 

Chapter IX. 
DISEASES OP THE OPTIC NERVE. 

PAGE 

Hyperemia of the Optic Nerve — Inflammation of the Optic Nerve — 
Atrophy of the Optic Nerve — Excavation of the Optic Nerve — Pig- 
mentation of the Optic Nerve — Tumors of the Optic Nerve — Opaque 
Optic Nerve Fibres 409-433 

Chapter X. 

AMBLYOPIC APPECTIONS. 

Amaurosis— Amblyopia — Hemeralopia — Color Blindness — Simulation of 

Amaurosis 434-462 

Chapter XI. 

DISEASES OP THE CHOROID. 

Hyperemia of the Choroid — Serous Choroiditis — Disseminated Choroiditis 
— Sclerotico-choroiditis Posterior — Suppurative Choroiditis — Colloid 
Disease of the Choroid — Tubercles of the Choroid— Tumors of the. 
Choroid, Sarcoma, Carcinoma — Formation of Bone — Coloboma of the 
Choroid — Rupture of the Choroid-^Heniorrhage from the Choroid — 
Detachment of the Choroid 463-499 

Chapter XII. 

GLAUCOMA. 

Acute Inflammatory Glaucoma — Chronic Inflammatory Glaucoma — Glau- 
coma Simplex— Secondary Glaucoma- — Ophthalmoscopic Symptoms 
of Glaucoma — The nature and Causes of the Glaucomatous Process — 
Prognosis of Glaucoma, etc 500-535 

Chapter XIII. 

THE ANOMALIES OP REFRACTION AND ACCOMMODATION OF 

THE EYE. 

The Refraction and Accommodation of the Eye' — Optical Lenses, etc. — 
Mechanism of Accommodation — Negative Accommodation — The 
Range of Accommodation — Myopia — Presb3'opia— Hypermetropia — 
Astigmatism — Aphakia — Paralysis, Spasm, and Atony of the Ciliary 
Muscle— Spectacles — Difference in the Refraction of the two Eyes 536-598 



PA HE 



Xli CONTENTS. 

Chapter XIV. 

AFFECTIONS OF THE MUSCLES OF THE EYE. 

Actions of the Muscles of the Eye— Paralysis of External Rectus— 
Paralysis of the Third Nerve— Paralysis of the Internal, Superior, 
and Inferior Recti— Paralysis of the Inferior and Superior Oblique- 
Nystagmus— Strabismus — Convergent Strabismus— Divergent Stra- 
bismus—Operations for Strabismus, Von Graefe's, Critchett's, Lie- 
hreich's — Muscular Asthenopia 599-657 

Chapter XV. 

DISEASES OF THE LACHRYMAL APPARATUS. 

Diseases of the Lachrymal Gland — Stillicidium Lacrymarum — Inflamma- 
tion of the Lachrymal Sac— Blenorrhcea of the Sac — Stricture of the 
Lachrymal Passages — Fistula of the Lachrymal Sac . . . 658-681 

Chapter XVI. 

DISEASES OF THE ORBIT. 

Inflammation of the Cellular Tissue — Periostitis — Caries and Necrosis — 
Inflammation of the Capsule of Tenon — Exophthalmic Goitre — 
Tumors of the Orbit — Vascular Tumors of the Orbit — Effusion of 
Blood — Emphysema — Pressure upon the Orbit from Neighboring 
Cavities — Wounds and Injuries of the Orbit — Excision of the Eyeball 
.-The Application of Artificial Eyes 682-725 

Chapter XVII. 

DISEASES OF THE EYELIDS. 

ffidema and Inflammation of the Eyelids — Syphilitic and Exanthematous 
Affections — Blepharitis Marginalis — Ephidrosis and Chromhydrosis — 
Hordeolum — Tumors of the Eyelids — Nsevus Maternus — Ptosis — 
Paralysis of the Orbicularis — Blepharospasm — Trichiasis and Distich- 
iasis — Entropium— Ectropium— Injuries, Wounds, etc., of the Eyelids 726-783 

Appendix. 

Mode of Examining the Field of Vision — Treatment of Chronic Granula- 
tions — Treatment of Symblepharon — Phlyctenular Corneitis — Treat- 
ment of Ulcers of the Cornea — Treatment of Conical Cornea — Treat- 
ment of Total Staphyloma of the Cornea and Iris — Leprous Tubercle 
of the Cornea — Inflammation of the Iris — Treatment of Inflammation 
of the Iris — Treatment of Irido-choroiditis — Operations for Cataract — 
Operation for Secondary Cataract — New Demonstrating Ophthalmo- 
scope of Brudenell Carter 785-800 

Explanation of the Plates 802-812 

Selections from the Test-types op Jaeger and Snellen . . 813-821 



LIST OF ILLUSTRATIONS. 



PIG. 

1. Upper eyelid everted .... 

2. Mode of everting the upper eyelid 

3. Mode of examining the eye by oblique illumination 

4. Mode of examining the eye by oblique illumination 

5. Mode of examining the visual field 
- 6. Mode of examining the visual field 

7. Diagram for demonstrating the punctum caecum 

8. Diagram explanatory of homonymous diplopia . 

9. Diagram explanatory of crossed double images . 

10. Diagram explanatory of action of pi-isms 

11. Liebreich's bandage .... 

12. Liebreich's bandage applied 

13. Catarrhal ophthalmia .... 

14. The eyelids in purulent ophthalmia 

15. Chemosis in purulent ophthalmia . 

16. The eyelids in gonorrhoeal ophthalmia 

17. Chemosis in early stages of gonorrhoeal ophthalmia 

18. Ophthalmia neonatorum .... 

19. The palpebral conjunctiva in granular ophthalmia 

20. Pterygium tenue ..... 

21. Pterygium crassum .... 

22. Szokalski's operation for pterygium 

23. Symblepharon ..... 

24. Mr. Teale's operation for symblepharon . 

25. Mr. Teale's operation for symblepharon . 

26. Mr. Teale's operation for symblepharon . 

27. Ankyloblepharon ..... 

28. The spud . ... 

29. Mr. Haynes Walton's gouge 

30. Dermoid tumor of the conjunctiva 

31. Dermoid tumor of the conjunctiva 

32. Dermoid tumor of the conjunctiva 

33. Pannus . . . . 

34. Phlyctenular corneitis .... 

35. Ulcer of the cornea .... 

36. Prolapse of the iris .... 

37. Paracentesis cornese .... 

38. Notched teeth of congenital syphilis 

39. Notched teeth of congenital syphilis 

40. Partial leucoma ..... 



XIV 



LIST OF ILLUSTRATIONS. 



HO. 

41. Knife for removing deposits of lead 

42. Conical cornea .... 

43. Kerato-glpbus .... 

44. Partial staphyloma of the cornea (side view) 

45. Partial staphyloma of the cornea (front view) 

46. Total staphyloma of the cornea 

47. Operation of excision of staphyloma 

48. Mr. Critchett's operation of abscission of staphyL 

49. Beer's cataract knife 

50. View of eye after Mr. Critchett's operation of abscission 

51. Knapp's operation for staphyloma 

52. Iritis 

53. Iritis with irregular pupil and lymph near margin 

54. Iritis with occlusion of the pupil . 

55. Iritis with slender adhesions to the capsule 

56. Serous iritis .... 

57. Mr. Laurence's pupillometer 

58. Rupture of the continuity of the iris 

59. Rupture of the iris at its great circumference 

60. Double pupil caused by laceration of the iris 

61. Cyst of the iris 

62. Coloboma iridis 

63. Weiss' stop speculum 

64. Straight keratome . 

65. Bent keratome 

66. Straight iris forceps 

67. Curved iris forceps . 

68. Iris scissors bent on the edge 

69. Iris scissors curved on the flat 

70. Iridectomy . 

71. Iridectomy . 

72. Iridectomy (Mr. Bowman's modification) 

73. Iridectomy (Mr. Bowman's modification) 

74. Appearance of the eye after iridectomy . 

75. Broad needle .... 

76. Diagram illustrating iridodesis 

77. Broad cilia forceps .... 

78. Canula forceps .... 

79. Pupil after iridodesis 

80. Artificial pupil made by incision of the iris 

81. Tyrrel'shook .... 

82. Spatula hook .... 

83. Cysticercus in the iris . 

84. Microscopic view of cysticercus . 

85. Appearance of the eye in sympathetic ophthalmia 

86. Anterior sclerotic staphyloma 

87. Anterior sclerotic staphyloma 

88. Annular staphyloma 

89. Cataract 

90. Diagram showing how dilatation of the pupil in cataract improves the 

• sight ........ 



243 



LIST OF ILLUSTRATIONS. 



XV 



FIG. 

01. Diagram showing how dilatation of the pupil in cataract improves the 
sight .... 

92. Morgagnian cataract 

93. Flap extraction by the upper section 

94. Flap extraction by the lower section 

95. Sichel's knife 
96 Flap extraction by the superior section 

97. The pricker 

98. Graefe's cystotome 

99. Passage of the lens through the corneal 

100. Mode of making the corneal flap . 

101. Probe-pointed secondary knife 

102. Hook .... 

103. Weber's lance-shaped knife 

104. Diagram illustrating Weber's operation for cataract 

105. Mr. Critchett's scoop .... 

106. Mr. Bowman's scoop .... 

107. Mr. Bowman's scoop (another form) 

108. Von Graefe's cataract knife 

109. The line of incision in modified linear extraction 

110. The line of incision in modified linear extraction 

111. Diagram illustrating Liebreich's operation for cataract 

112. Bowman's fine stop needle 

113. Hays's knife-needle .... 

114. Hays's knife-needle (magnified view) 

115. Diagram showing how dilatation of the pupil in cataract improves the 

sight .... 

116. Diagram showing how dilatation of the pupil in cataract improves the 

sight ...... 

117. View of the artificial pupil made by iridectomy 

118. View of the artificial pupil made by iridodesis , 

119. Mr. Teale's suction curette 

120. Mr. Bowman's suction syringe . 

121. Extraction of chalky cataract 

122. Partial dislocation of the lens 

123. Complete dislocation of the lens into the anterior chamber 

124. Dislocation of the lens beneath the conjunctiva. 

125. Diagram illustrating the reflection of light from the eye 

126. Diagram illustrating the principle of Helmholtz's ophthalmoscope 

127. Diagram illustrating the ophthalmoscopic examination of the actual in 

verted image 

128. Diagram illustrating the ophthalmoscopic examination of the virtual 

erect image .... 

129. Ophthalmoscope of Liebreich . . ■ 

130. Ophthalmoscope of Coccius 

131. Ophthalmoscope of Coccius (original form) 

132. Ophthalmoscope of Loring 

133. Diagram illustrating the mode of action of Giraud Teulon's binocular 

ophthalmoscope 

134. Section of the binocular ophthalmoscope of Messrs. Laurence and 

Heisch .... 



XVI 



LIST OF ILLUSTRATIONS. 



FIG. 

135. Diagram illustrating the optical action of the same 

136. Manner of using the binocular ophthalmoscope 

137. Diagram illustrating the optical action of Giraud-Teulon's aut-ophthal 

moscope ........ 

138. Ophthalmoscopic examination of the actual inverted image 

139. Diagram illustrating Mr. Bowman's operation for subretinal effusion 

140. Glioma retinae ....... 

141. Fungus hsematodes of eye ..... 

142. Microscopical appearance of glioma .... 

143. Diagram showing the decussation of the fibres of the optic nerve 

144. De Wecker's trephine ...... 

145. Diagram explanatory of the focus of a biconvex lens . 

146. Diagram explanatory of the focus of a biconvex lens . . 

147. Diagram explanatory of the secondary axis of a biconvex lens 

148. Diagram illustrating the mode in which a biconvex lens forms an 

image of an object in front of it 

149. Diagram illustrating how a biconvex lens magnifies 

150. Diagram illustrating the course of rays of light passing through a hi 

concave lens ....... 

151. Diagram illustrating the mode in which the reverse image of an object 

is formed upon the retina ..... 

152. Diagrammatic eye of Listing ..... 

153. Diagram illustrating the visual angle .... 

154. Diagram illustrating the effect of accommodation 

155. Diagram illustrating myopia ..... 

156. Diagram illustrating hypermetropia .... 

157. Diagram illustrating the changes which the eye undergoes during ac 

commodation ....... 

158. Diagram explanatory of the ophthalmoscopic appearance of a myopic 

eye ....... 

159. Diagram explanatory of the ophthalmoscopic appearance of a hyper 

metropic eye ....... 

16,0. Diagram illustrating the focal distance in the vertical and horizontal 
meridian in astigmatism ..... 

161. Diagram illustrating the focal distance in the vertical and horizontal 

meridian in astigmatism 

162. Diagram illustrating the focal distance in the vertical and horizontal 

meridian in astigmatism ..... 

163. Dr. Green's test object for detecting astigmatism 

164. Javal's optometer ....... 

165. Thomson's optometer ..... 

166. Blackened disk for determination of astigmatism 

167. Diagram showing hypermetropia and myopia . • . 

168. The muscles of the eyeball ..... 

169. Linear measurement of squint .... 

170. Mr. Laurence's strabismometer ..... 

171. Dr. Galezowski's binocular strabismometer 

172. Diagram explanatory of diplopia in paralysis of the external rectus 

173. Diagram explanatory of the difference in height of the double images 

in paralysis of the external rectus .... 



610 



LIST OF ILLUSTRATIONS. 



XV11 



FIG. 

174. Mr. Bowman's diagrammatic record of the extreme lateral movements 

of the eye ........ 

175. Mr. Bowman's diagrammatic record of the extreme lateral movements 

of the eye . . . 

176. Finely pointed forceps 

177. Probe pointed scissors, curved on the flat 

178. Strabismus hook with bulbous point 

179. Straight blunt-pointed scissors 

180. Strabismus hook .... 

181. Theobald's crochet hook 

182. Von Graefe's test for insufficiency of the internal recti 

183. Grooved director for slitting up the canaliculus 

184. Mr. Bowman's probe (No. 6) 

185. Weber's beak-pointed knife 

186. Weber's graduated biconical sound 

187. Dr. Hays's probe .... 

188. Dr. Sailing's knife 

189. Manfredi's speculum 

190. Eversion of lid owing to necrosis of orbit 

191. Ectropium the result of caries of the margin of the orbit 

192. Ectropium the result of caries of the margin of the orbit 

193. Ivory exostosis in the orbit .... 

194. Cystic tumor of orbit ..... 

195. Scirrhus of the orbit ..... 

196. Present appearance of patient from whom the above bone was removed 

197. Appearance of patient with medullary cancer of orbit 

198. Appearance of same patient after operation 

199. Aneurism by anastomosis in orbit 

200. Appearance of patient with abscess of frontal sinus 

201. Appearance of same patient after operation 

202. Portion of hat-peg which was impacted in orbit 

203. Blunt-pointed scissors curved on the flat 

204. Chalazion ....... 

205. Cutaneous horn growing from lower lid 

206. Trichiasis ....... 

207. Horn spatula ...... 

208. Snellen's modification of Desmarres' clamp 

209. Snellen's modification of Desmarres' clamp applied 

210. Mr. Laurence's modification of Snellen's clamp 

211. Diagram illustrating Herzenstein's operation for trichiasis 

212. Diagram illustrating Arlt's modification of Jaesche's operation for trichi 

asis ....... 

213. Diagram illustrating Von Graefe's operation for trichiasis 

214. Diagram illustrating Anagnostakis's operation for partial trichiasis of 

upper lid 

215. The same 

216. The same 

217. Spasmodic entropium 

218. Entropium forceps 

219. Another form of the same 

220. Diagram illustrating Von Graefe's operation for spasmodic entropium 

B 



025 



XV111 



LIST OF ILLUSTRATIONS. 



FIG. 

221. Diagram illustrating Von Graefe's operation for spasmodic entropium 

222. Diagram illustrating Von Graefe's operation for spasmodic entropium 

223. Desmarres' forceps ...... 

224. Ectropium .... 

225. Ectropium .....-• 

226. Ectropium caused by cicatrix ..... 

227. Sir William Adams's operation for ectropium . 

228. Appearance of the eye after Adams's operation for ectropium . 

229. Diagram illustrating Mr. Wharton Jones's operation for ectropium 

230. Appearance of the eye after Mr. Wharton Jones's operation for ectro 

pium ........ 

231. Diagram illustrating Dieffenbach's operation for ectropium 

232. Appearance of the eye after Dieffenbach's operation for ectropium 

233. Diagram illustrating Von Graefe's operation for ectropium 

234. Blepharoplastic operation for ectropium . . 

235. Method of fastening the flap in the blepharoplastic operation . 

236. Dieffenbach's blepharoplastic operation for ectropium . 

237. Dieffenbach's blepharoplastic operation for ectropium . 

238. Vertical cut of tarsal edge of lower lid . 

239. Operation for epicanthus ... . 

240. Carter's perimeter ...... 

241. Teale's operation by transplantation for symblepharon 

242. De Wecker's operation for total staphyloma of cornea and iris 

243. Diagram illustrating line of incision in operation for cataract . 

244. Lebrun's operation for cataract ..... 

245. Diagram illustrating line of incision in De Wecker's operation for 

secondary cataract ...... 

246. De Wecker's forceps scissors ..... 

247. Carter's demonstrating ophthalmoscope 

248. Diagram illustrating the arrangement of Carter's demonstrating oph 

thalmoscope ........ 



PAGE 

764 

764 
766 
767 
767 
769 
772 
772 
773 

773 
773 
773 
774 
776 
776 
777 
777 
781 
782 
785 
786 
792 
796 
797 

798 
798 
799 

800 



COLORED OPHTHALMOSCOPIC PLATES. XIX 



COLORED OPHTHALMOSCOPIC PLATES. 



Plate I. to face p. 802. 

Fig. 1. — The normal fundus oculi of a brunette. 
Fig. 2. — The normal fundus oculi of a blonde. 

Plate II. to face p. 804. 

Fig. 3. — Sclerotico-choroiditis posterior. 
Fig. 4. — Choroiditis disseminata syphilitica. 

Plate III. to face p. 806. 

Fig. 5. — Retinitis pigmentosa. 
Fig. 6. — Retinitis albuminurica. 

Plate IV. to face p. 808. 

Fig. 7. — Retinitis apoplectica. 

Fig. 8. — Embolism of the central artery of the retina. 



Plate V. to face p. 810. 

Fig. 9. — Cysticercus in the vitreous humor. 
Fig. 10. — Detachment of the retina. 



Plate VI. to face p. 812. 

Figs. 11 and 12. — Atrophy of the optic nerve. 

Figs. 13 and 14. — Optic neuritis. 

Figs. 15 and 16. — Glaucomatous excavation of the optic nerve. 



CORRIGENDUM. 

Page 124, in line 24, for "Bals. peruv. 9 lbs. 6 to 10," read "Bals. 
perav. n 10—15." 



A TREATISE 



DISEASES OF THE EYE 



INTRODUCTION. 

In order to avoid unnecessary repetition in the course of this 
work, I think it advisable to give in this introduction a brief 
description of some of the more important and frequent modes of 
examination of the eye, as well as of certain remedies and appli- 
ances in common use in ophthalmic practice. 

Eversion of the upper eyelid has frequently to be practised if the 
presence of a foreign body is suspected beneath it, or if certain 
remedies are to be applied to its lining membrane. Various con- 
trivances have been suggested for facilitating this proceeding, but 
it is best done in the following manner: The patient being di- 
rected to look downwards, the surgeon seizes lightly the central 
lashes of the upper lid between the forefinger and thumb of his 
left hand, and draws the lid downwards, and somewhat away from 
the eyeball. He next places the tip of the forefinger of his right 
hand on the centre of the lid, 
about half an inch from its free 
margin. "With a quick movement, 
the edge of the lid is to be then 
turned over the tip of the fore- 
finger (which should be simulta- 
neously somewhat pressed down- 
wards). By slightly pressing the 
margin of the everted lid back- 
wards against the upper edge of 
the orbit, the whole retro-tarsal 
fold will spring into view, and the 
lid become fully everted. [Fig. 1.] 
In those exceptional cases in which 
the patient i^ very unmanageable, 
and forcibly contracts the orbicu- 
laris muscle, it may be necessary to use a probe, or the end of a 
quill pen or pencil, over which to turn the lid, instead of the fore- 
2 




18 



INTRODUCTION". 



finger. [Fig. 2.] But as a rule it is more convenient to employ 
the latter, as we may not always have a probe at hand, and as 




anything in the shape of an instrument frightens some patients, 
whereas we may often succeed in everting the lid with the finger, 
before they have even time to resist. The surgeon may also stand 
behind the patient, and steady the head of the latter against his 
breast, aud evert the lid from behind. 

The oblique or focal illumination is in constant requisition for 
ascertaining the condition of the structures of the anterior half of 
the eyeball. By its aid we are enabled to examine, with great 
minuteness, the appearances presented by the cornea, iris, pupil, 
lens, and even the most anterior portion of the vitreous humor 
[and to detect foreign bodies in the anterior chamber, delicate false 
membranes in the pupillary space, minute deposits upon the iris 
and capsule of the lens, and slight nebulae of the cornea, which 
would often escape the observation of the unaided eye]. This 
mode of examination is to be thus conducted : A # lamp being 
placed somewhat in front and to one side of the patient, at a dis- 
tance of from 2 to 2J feet (Fig. 3), and on a level with his eye, the 




light is concentrated upon the cornea or the crystalline lens by a 
strong bi-convex lens of 2 — 2J inches focus. The observer's eye 



INTRODUCTION. 



19 



is then to be placed on one side of the patient, so as to catch the 
rays emanating from the eye of the latter. By shifting the cone 
of light from one portion of the cornea or lens to another, we 
may rapidly, yet thoroughly, examine its whole expanse and detect 
the slightest opacity. In order to gain a larger image, we may 
employ a second lens as a magnifying glass [which should be held 
directly in front of the patient's eye. (Fig. 4)]. Opacities of the 




cornea or lens will appear by the oblique illumination (reflected 
light) of a light gray or whitish color, whereas with the ophthal- 
moscope (transmitted light) they will appear as dark spots upon a 
bright red background. 

The method of examining the eye with the ophthalmoscope will 
be found described, at length, in the section upon the ophthalmo- 
scope. 

The mode of ascertaining the degree of intra-ocular tension is as 
follows : The patient being directed to look slightly downwards, 
and gently to close the eyelids, the surgeon applies both his fore- 
fingers to the upper part of the eyeball behind the region of the 
cornea. The one forefinger is then pressed slightly against the eye 
so as to steady it, whilst the other presses gently against the eye, 
and estimates the amount of tension, ascertaining whether the- 



20 INTRODUCTION. 

globe can be readily dimpled, or whether it is perhaps of a stony 
hardness, yielding not in the slightest degree even to the firm 
pressure of the finger. The beginner will do well to make him- 
self thoroughly conversant with the normal degree of tension, by 
the examination of a number of healthy eyes, and then, if he 
should be at all in doubt as to the degree of tension in any indi- 
vidual case, he should test the tension of the patient's other eye 
(if healthy), or that of some normal eye, so as to be able to draw a 
comparison between them. If there is much oedema of the lids, 
or conjunctival chemosis, or if the eyes are small and deeply set, 
it may be difficult accurately to estimate the degree of tension. 1 

I would call particular attention to the signs which Mr. Bowman 
has devised for the designation of the different degrees of tension 
of the eyeball, as they will be found most useful, not only in prac- 
tice, but also in the reporting of cases, or in the preservation of an 
accurate record of the state of tension. 

Mr. Bowman introduced this subject to the attention of the pro- 
fession in 1862, in his admirable paper " On Glaucomatous Affec- 
tions, and their Treatment by Iridectomy," read before the Annual 
Meeting of the British Medical Association, 2 in which he says, " I 
have long paid special attention to the subject of tension of the 
globe, and particularly since it has assumed so much additional 
importance in the last few years. I have found it possible and 
practically useful to distinguish nine degrees of tension ; and, for 
convenience and accuracy in note-taking, have designated them 
by special signs. The degrees may be thus' exhibited : — 3 

" T represents tension (' t ' being commonly used for ' tangent,' 
the capital T is to be preferred). Tn, tension normal. The inter- 
rogative, ?, marks a doubt, which in such matters we may often be 
content with. The numerals following the letter T, on the same line, 
indicate the degree of increased tension ; or if the T be preceded 
by — , of diminished tension, as further explained below. Thus : — 

" T 3. Third degree, or extreme tension. The fingers cannot 
dimple the eye by firm pressure. 

" T 2. Second degree, or considerable tension. The finger can 
slightly impress the coats. 

" T 1. First degree, slight but -positive increase of tension. 

" T 1 ? Doubtful if tension is increased. 

" Tn. Tension normal. 

1 In order, if possible, to estimate the degree of intra-ocular tension with extreme 
nicety, instruments, termed tonometers, have been devised by Von Graefe, Don- 
ders, Dor, etc. It must, however, be admitted that the results obtained by them 
were not sufficiently accurate to render them preferable to the palpation by the 
fingers. But more lately Monnik has invented a tonometer, which appears to 
answer well, and which is constructed on the principle of indicating the depth to 
' which a minute pin, connected with the instrument, is pressed into the sclerotic, 
and also the force employed to produce the depression. For a further account of 
it, vide Kl. Monatsbl. 1868, p 364, and Annales d'Oculistique, 1869, p. 68. 

"- British Medical Journal, Oct. 11, 1862, p. 378. 

3 " Since this paper was read I have simplified the signs, with the concurrence 
of my friend, Professor Donders, in order to adapt them for general use. The 
simplified form has been substituted above." 



INTEODUOTION'. 21 

" — T 1 ? Doubtful if tension be less than natural. 

" — T 1. First degree of reduced tension. Slight but positive 
reduction of tension. 

" — T 2 ) Successive degrees of reduced tension, short of such 

" — T 3 j considerable softness of the eye as allows the finger to 
sink in the coats. It is less easy to define these by words. 

" In common practice, some of these may be regarded as refine- 
ments ; but in accurate note-taking, where the nature and course 
of various diseases of the globe are under investigation, I have 
found them highly serviceable, and they have as much precision 
as perhaps is attainable or desirable. 

" It is also to be borne in mind that the normal tension has a 
certain range or variety in persons of different age, build, or tem- 
perament ; and according to varying temporary states of system 
as regards emptiness and repletion. Experience will make every 
one aware of these varieties, which do not encroach on the above 
abnormal grades of tension. Medical men may understand how 
important is this matter of the degree of tension, by considering 
how priceless would be the power of accurately estimating it by 
the touch in the case of various head affections." 

For the examination of the acuteness of vision various test-types 
are used, more especially those of Jaeger and Snellen. The former 
do not, however, afford a perfect clue to the acuteness of vision, 
for a person may be able to read 2STo. 1 of Jaeger with facility and 
yet not enjoy a normal acuteness of sight. Snellen has, however, 
devised a set of test-types which fulfil this desideratum. The 
letters are square, and their size increases at a definite ratio, so 
that each number is seen at an angle of five minutes. Thus, No. 
1 is seen by a normal eye up to a distance of one foot, at an angle 
of five minutes, No. 2 up to two feet, and so on. These numbers 
cannot, as a rule, be seen distinctly beyond these distances. 1 

Now, if the eye is suffering from any diminution of acuteness of 
vision, it will require to see the letters under a larger angle than 
that of five minutes, in order to gain larger retinal images. No. 1 
cannot be read at a distance of one foot, but only, perhaps, No. 4 
or 5. "We may easily calculate the degree of the acuteness of 
vision thus : — 

" The utmost distance at which the types are recognized (d) divided 
by the distance at which they appear at an angle of five minutes (D), 

gives the formula for the acuteness of vision (V): V= — . 

1 At Professor Longmore's suggestion, Dr. Snellen has given in his second edi- 
tion of the test-types some tables containing a series of figures and single numbers, 
for the examination of such recruits for the British Army as are unable to read. 
For further information as to the examination of the sight of recruits, I must refer 
the reader to Professor Longmore's excellent "Ophthalmic Manual," which I 
would also recommend to the special notice of the surgeons of the Militia and Vol- 
unteer Corps. These test-types may be obtained at Messrs. Williams and Norgate's, 
Henrietta-street, Covent Garden. 

[A selection from the test-types of both Jaeger and Snellen, sufficient for use in 
ordinary practice, will be found at the end of this volume.] 



22 INTRODUCTION. 

" If d and D be found equal, and No. 20 be thus visible at a 

20 
distance of twenty feet, then V=^= 1; in other words, there is 

normal acuteness of vision. If, on the contrary, d be less than D, 
and if No. 20 is only visible within ten feet, No. 10 only within 
two feet, No. 6 only within one foot, these three cases are thus 
respectively expressed : — 

20 2 ' . 10 5 ' 6 

d may sometimes be greater than D, and, No. 20 be visible at a 
greater distance than 20 feet. In this case vision is more acute 
than the normal average." 

It must, however, be confessed that some patients (more espe- 
cially amongst the lower classes) often experience a difficulty iu 
fluently reading type composed of these square letters. They have 
always been accustomed to ordinary type, the letters of which are 
of unequal thickness, and differ both in dimension and definition. 
I, therefore, generally employ Jaeger's test-types for ascertaining 
the fluency with which small print can be read, and those of Snellen 
for testing with accuracy the acuteness of vision. 

Besides examining the acuteness of vision, it is often of much 
importance to ascertain with accuracy and care the condition of 
the field of vision, which may be readily done in the following 
manner : The patient, being placed straight before us at a distance 
of from fifteen to eighteen inches, is directed to look with the eye 
under examination (closing the other with his hand) into one of 
our eyes, his right eye being fixed upon our left, and vice versd. 
In this way any movement of the eye may be at once detected and 
checked. Whilst he still keeps his eye steadily fixed upon ours, 
we next move one of our hands in different directions throughout 
the whole extent of the field of vision (upwards, downwards, and 
laterally), and ascertain how far from the optic axis it is still visi- 
ble ; we then approach the hand nearer to the optic axis, and ex- 
amine up to how far from it he is able to count fingers in different 
directions. The number of the extended fingers is to be constantly 
changed, and the examination to be repeated several times, so that 
we may ascertain whether the patient can count them with cer- 
tainty, or whether he hesitates in his answers, or only guesses at 
their number. We may thus readily discover whether the field 
of vision is of normal extent, or whether it is defective or altogether 
wanting in certain directions. 

We may term that part of the field in which the patient can 
still distinguish an object (a hand, a piece of chalk, etc.) the quan- 
titative field of vision, in contradistinction to that smaller portion 
in which he is able to count fingers, and which may be designated 
the qualitative field. 

The following method of examining the field is still more accu- 



INTRODUCTION. 23 

rate, and I should advise its adoption in all cases where it is of 
importance to have an exact map of the extent of the field, as in 
glaucoma, detachment of the retina, etc., so that a record may be 
kept of the condition of the field during the progress of the dis- 
ease, or that we may be able to compare its extent before and after 
an operation. The patient, being placed before a large black board, 
at a distance of from 12 to 16 inches, is directed to close one eye 
and to keep the other steadily fixed upon a chalk dot, marked in 
the centre of the board and on a level with his eye. A piece of 
chalk, fixed in a dark handle, is then gradually advanced from 
the periphery ot the board towards the centre, and the spot where 
the chalk first becomes visible is then marked upon the board. 
This proceeding is to be repeated throughout the whole extent of 
the field ; the different points at 
which the object first becomes [Fig. 

visible are then to be united by a 
line, which indicates the outline 
of the quantitative field of vision. 
[Fig. 5.] The extent of the quali- 
tative visual field is next to be ex- 
amined, and it is to be ascertained 
how far from the central spot the 
patient can count finders in diffe- 
rent directions. The points thus 
found are also to be marked on the 
board, and the marks afterwards 
united with each other by a line, 
which should be of a different 
color or character to that indicat- 
ing the extent of the quantitative 

field, so that the two may not be confounded. It need hardly be 
mentioned that care is to be taken that during the examination 
the patient's eye remains steadily fixed upon the central spot, that 
the other eye is kept closed, and that his distance from the board 
is not altered. The extent of the field inwards will, naturally, vary 
according to the prominence of the patient's nose. 

It is still more convenient to map out the field upon a large 
piece of blue paper placed against the board, as this saves us the 
trouble of copying the map from the latter. Such maps are to be 
kept for future reference, or for comparison with others that may 
be taken of the same case at a later period. If this, however, can- 
not be done, we may keep a record of the shape of the field, and of 
the distance to which the patient can see in different segments of 
it by the following simple expedient which I have for some time 
adopted. 

The board is to be divided into four equal parts by a vertical 
and horizontal line (of about 4 feet in length), cutting each other 
at the central cross ; each quadrant is then again to be divided into 
two equal parts by another line, so that the whole is divided into 
eight equal segments, as in the accompanying figure (Fig. 6) which 




24 



INTRODUCTION. 



represents the division of the field for the left eye. For the right 
eye the position of the letters must be reversed, thus u i (upwards 
and inwards) would be u o (upwards and outwards), and so with 
all the others. 

The meaning of the letters is as follows : — 

V M — Vertical Meridian, dividing the field into two lateral 
halves (inner and outer). 

MM — Horizontal Meridian, dividing the field into an upper and 
a lower half. 

The upper half of the field is subdivided into four segments : — 

u o upper and outer segment. 
o u outer " upper " 
u i upper " inner " 
i u inner ' ; upper " 

The lower half is also subdivided into four segments: — 

I outer and lower segment. 

1 o lower " outer " 
i I inner " lower " 
I i lower " inner " 



Fig. 6. 

Left Eye. 

VM 



HM 





u o 


It 1 




u 






I u 


ol 






i"Z 




Jo 


1 1 


\ 



The method of examining the patient's field of vision is to be the 
same as that above described, when a plain board was used. The 
object of the divisions is only to furnish a kind of framework for 



INTRODUCTION. 25 

the map of the field, which enables us to sketch it with more ease 
and rapidity. The boundary of the quantitative and qualitative 
fields is to be marked both upon and between each of the divisional 
lines, and the distance of each of these marks from the centre of 
the board is then to be measured, and its extent, in inches, is to be 
placed against each mark. A small fac-simile of the field of vision 
thus mapped out may then be drawn in the note-book, the field 
being here also divided into eight segments, the boundaries and 
measurements of the map being likewise copied ; so that we may 
preserve, in a small and convenient form, an accurate record of the 
shape and extent of the visual field. 

But the sight of the patient may be so much impaired that he 
can no longer count fingers, even in the optic axis, being only able 
to distinguish between light and dark, as in cases of mature cata- 
ract, severe cases of glaucoma, etc., and yet it may be of great 
importance to know whether or not the field of vision is of normal 
extent. This may be readily ascertained in the following manner: 
The patient is directed to look with the one eye (the other being 
closed) in the direction of- his uplifted hand (held straight before 
him, on a level with his eye, and at a distance of from 12 to 18 
inches). A lighted candle is then held in different portions of the 
visual field, and the furthest point at which it is still visible in 
various directions is noted, the candle being alternately shaded 
and uncovered by our hand, so as to test the readiness and accuracy 
of the patient's answers. Care should also be taken to shade the 
candle when it is removed to another portion of the field. The 
light may likewise be thrown upon various portions of the eyeball 
by the mirror of the ophthalmoscope, and the patient questioned as 
to the direction from which the light appears to come. 

Mr. Pridgin Teale has devised a modification of the above method, 
by subdividing the board (already divided by vertical, horizontal, 
and diagonal lines) by a series of concentric circles. There is, more- 
over, a travelling white disk of card-board, which can be moved 
from the outer edge of the board to the' centre along the diagonal 
and other lines, thus forming a very convenient and easily recog- 
nizable object. There is also a rest to steady the patient's head, 
and maintain it at a certain distance. He marks the existence of 
good vision by a -f sign, imperfect vision by — , and absence of 
vision by 0. Blank diagrams 1 are prepared, which are a copy of 
the markings on the board, on a scale of I of an inch to 1 inch of 
the board. 

"Wecker employs the following mode of taking the field. He 
uses a large black board, towards the centre of which can be moved, 
in a radiating direction, a number of small white ivory balls, thus 
marking the" extent of the field ; as soon as the ball reaches the 
limit of the field, it is turned round, and presents its black pos- 
terior surface to the patient. On the back portion of the board, 

1 These may be obtained at Messrs. Harrison's, 45 St. Martin's Lane. 



26 INTRODUCTION. 

the shape and extent of the field can be read off from the position 
of the white balls, which give its exact delineation. 

Professor Fdrster's Perimeter 1 is, however, by far the best instru- 
ment for measuring the extent of the field of vision. It consists 
of a semicircular band of brass, which is mounted on a stand. 
This band or arc is 2 inches wide, and curved at a radius of 12 
inches ; it revolves round a central axis, which permits of its being 
placed in different meridional positions. Each half of the arc is 
divided into 90° ; 0° being situated in the middle, at the central 
axis, and the 90° at each extremity. The object for testing the 
field consists of a small black movable knob, having a white centre; 
this knob can be rapidly run along to any point of the arc by 
means of a couple of strings worked from behind by a winch. At 
the back of the central axis is a graduated disk, on which a needle 
indicates the various meridians in which the arc is placed, and its 
inclination to the vertical meridian ; also the degrees, from 0° to 
180°, within these meridians. In order to note the extent of the 
field in different directions, and to record the results, Forster has 
devised small circular maps, which are copies of the disk, and of 
the degrees of latitude within each meridian. On these skeleton 
maps can be readily traced the extent of the field in any given 
case. In examining the field of a patient, he is not to have his 
visual line fixed on the centre (axis) of the arc, but on a little 
button placed 15° to the inner (nasal) side of the centre, so as to 
bring the blind spot opposite the latter. 2 

1 For a fuller description of this instrument, and the method of using it, I must 
refer the reader to Dr. Carl Moser's Inaugural Dissertation on the Perimeter 
(Breslau, 1869, published by H. Lindner) ; also to the Compte Kendu du Congres 
D' Ophthalmologic, 1867, p. 125. The perimeter is made by Mr. Sitte, optician, 8 
Alte Taschenstrasse, Breslau, and costs about £7. 

2 In order to avoid unnecessary repetition, I must here explain the signification 
of the terms "visual line" and "blind spot." By visual line is understood the 
imaginary line drawn from the yellow spot to the object point, and this line was 
formerly supposed to be identical with the optic axis, hence it is often said when a 
person is looking at an object, " that his optic axes are fixed upon it." This is, 
however, not strictly correct, for Helmholtz has shown that tlie visual line and 

Fig. 7. 




optic axis are not identical, but that the former lies on the cornea, more or less 
inwards, and somewhat upwards of the optic axis ; its posterior (retinal) extremity 



INTRODUCTION. 



27 



Double images {diplopia). — An object only appears single when 
both visual lines are fixed upon it ; any pathological deviation of 
either visual line must necessarily cause diplopia, as the rays from 
the object do not then fall upon identical portions of the retina. 
The slightest degree of diplopia is that in which the double images 
are not distinctly defined, but seem to lie slightly over each other, 
so that the object appears to have a halo round it. 

"We meet with two kinds of double images. 

1. Homonymous (or direct) diplopia, in which the image to the 
right of the patient belongs to his right eye, the left image to the 
left eye. 

2. Grossed double images, in which case the image to the right 
of the patient belongs to his left eye, that on his left to his right 

e y e - ' . . 

Homonymous diplopia is always produced (except in incon- 
gruence of the retinae) in convergent squint, for if the 'eye deviates 
inwards from the object, the rays 
coming from the latter will fall upon 
the inner portion of the retina and 
the image will (in accordance with 
the laws of projection) be projected 
outwards, as in Fig 8. 

Let I. be the right eye, whose 
visual line is fixed upon the object 
(b). II. The left eye, whose visual 
line (c d) deviates inwards from the 
object; the rays from b therefore fall 
upon e, a portion of the retina inter- 
nal to the yellow spot (d), and the' 
image is consequently projected out- 
wards to f ; b and f are, therefore, 
homonymous double images, the 
image b, which" is to the right of 
the patient, belonging to his right eye, the image f to his left 
eye. 

Crossed double images arise in divergent squint, for as the one eye 

consequently lying to the outer side of the optic axis, and somewhat below it. A 
fuller description of this will be found in Chapter XIII. 

The nerve fibres of the optic nerve are not excited by objective light, hence the 
light which falls on the entrance of the optic nerve (optic disk) is not perceived, 
and a corresponding gap exists in the field of vision. This gap or deficiency is 
called the blind spot, or punctum csecum, and corresponds In size and position to 
the optic disk. This fact is proved by the following experiment. If the left eye 
of the observer is closed, and the right eye fixed steadily on the cross in Fig. 7, it 
will be found that when the book is removed to about 12 inches from the eye, the 
white circle entirely disappears, and the whole figure is black. This gap in the 
visual field is not perceived because our vision is binocular, and the defect in the 
one eye is compensated for by the other. Moreover we pay but little attention to 
impressions which fall upon those parts of the retina which lie at a little distance 
from the point of fixation. The diameter of the blind spot is, according to Helm- 
holtz, 1 mm, 81. According to Listing, 1 mm, 55. Vide Helmholtz, Physiologische 
Optik., p. 209. 




II. 




28 INTRODUCTION. 

deviates outwards from the object, the rays from the latter fall upon 
a portion of the retina external to the macula lutea, the image is 

projected inwards, and crosses that 
Fig. 9. of the other eye, as in Fig. 9. 

I. The right eye, whose visual 
line is fixed upon the object (b). II. 
The left eye, whose visual line (c d) 
deviates outwards from the object ; 
the rays from the latter therefore 
fall upon e, a portion of the retina 
external to the macula lutea (d), and 
the image is projected to f, crossing 
the image b ; the image f, which 
would lie on the patient's right 
hand, would, therefore, belong to 
his left eye, the image b, which 
Would lie on his left side, to the 
right eye. 

If one eye squints upwards, the 
rays will fall upon the upper portion of the retina, and the image 
be projected beneath that of the healthy eye. The reverse will be 
the case if the eye squints downwards, for then the rays will fall 
upon the lower portion of the retina, and the image will be pro- 
jected above that of the healthy eye. 

We should never forget to ascertain whether the diplopia be 
monocular or binocular; in the latter case, it will of course dis- 
appear upon the closure of either eye. 1 

Let us now glance at the action of prisms. "When a ray of light 
falls upon a prism, it is refracted towards its base. If, for instance, 
whilst we look at an object (e. g., a lighted caudle) at 8 feet distance, 
with both eyes, a prism, with its base towards the nose, is placed 
before the right eye, the rays from the candle will be deflected 
towards the base of" the prism, and fall upon a portion of the retina 
internal to the yellow spot, and be consequently projected outwards, 
giving rise to homonymous diplopia. As we are, however, very 
susceptible of double images, the eye will endeavor to unite them 
by an outward movement (its external rectus becoming contracted), 
which will again bring the rays upon the yellow spot, but at the 
same time of course cause a divergent squint. Fig. 10 will explain 
this. Let a b be the visual line of the left eye fixed (with the 
other) upon a candle 8 feet oft'. Now, if a prism (with its base 
towards the nose) be placed before the right eye, the rays are re- 
fracted towards the base of the prism and do not, as in the other 

1 In examining the double images of a patient, it is convenient to place a slip of 
red glass before the sound eye, for we thus enable him readily to distinguish the 
two images by their color, and we also weaken the intensity of the image of the 
sound eye, and approximate it more to that of the affected one, whose image, owing 
to the rays from the object falling upon an eccentric portion of the retina, will be 
less intense in proportion to the distance of the spot, upon which the rays fall, from 
the macula lutea. 



INTRODUCTION. 



29 



Fig. 10. 




eye, fall upon the yellow spot, but 
upon a portion of the retina (d) in- 
ternal to the latter, and the image 
is projected outwards to e ; homo- 
nymous diplopia therefore arises, 
and to avoid this the external rectus 
muscle contracts and moves the eye 
outwards, so as to bring the macula 
lutea (c) to that spot (d) to which 
the rays are deflected by the prism. 
As the rays from the object will 
now fall in both eyes upon the ma- 
cula lutea, single vision will result, 
accompanied, of course, by a diver- 
gent squint of the right eye. 

The reverse will occur if we turn the prism with its base to the 
temple, for then the rays will be deflected to a portion of the retina 
to the outer side of the macula lutea, and the image will be pro- 
jected inwards across that of the left eye, and crossed diplopia will 
be the result. In order to remedy this, the internal rectus will 
contract and move the eye inwards, so as to bring the macula lutea 
to that spot to which the rays are deflected. 

The Compress Bandage. — The form of bandage to be employed, as 
well as its mode of application to the eye, is of much practical 
importance, and it should vary according to the effect which we' 
desire to produce. If the bandage is applied only for the purpose 
of keeping the dressing upon the eye, of preventing the movement 
of the latter and of the eyelids, or of guarding the eye against the 
effect of light or cold, it need but be of a very simple kind, and I 
think Liebreich's bandage answers these purposes best. But Von 
Graefe has shown that the compress and bandage may often be 
made of great therapeutical value, especially in arresting and limit- 
ing suppurative inflammation of the cornea, such as is apt to occur 

[Fig, 11.] 




in old and decrepit persons after injuries to the cornea, or an opera- 
tion {e.g., extraction of cataract). In such cases Liebreich's band- 
age does not suffice, and we must employ the pressure-bandage of 
von Graefe. 




INTRODUCTION. 

Liebreich's bandage [Fig. 11] 
consists of a knitted cotton band 

[a] about 12 incbes long and 1\ 
inches wide. At the one end are 
two tapes, the one [c] going round 
the back of the bead, the other 

[b] forming a cross-bar with the 
first, and passing over the top of 
the head. The other end of the 
bandage also carries a tape [e] 
which is to be tied at the side of 
the head, opposite the affected 
eye, to the one [cd] coming round 
from the back. [Fig. 12 represents 
the bandage applied.] The prin- 
cipal advantages offered by this 
bandage are— -that it perfectly 
retains its position without slip- 
ping, and that it can be undone 
and the dressings changed with- 
out the patient's head having to 
be raised from the pillow. If the 
thick knitted band proves heavy 
and hot, I substitute for it a band 

of fine muslin or of elastic web. The bandage is to be applied over 
the following dressing : The patient being directed gently to close 
his eyes, a piece of soft linen is laid over the lids so as to soak up 
any discharge, small oval pledgets of charpie 1 or carded cotton-wool 
are then placed over this, more especially in the hollows at the 
inside of the eyeball and beneath the upper edge of the orbit, so as 
to fill these out, and bring the padding nearly to the same level as 
in the centre. The pressure of this cushion should be quite uniform, 
and not greater upon one portion of the eye than another, more 
especially upon the centre of the eyeball, otherwise it will produce 
pain and discomfort. The succession of the pledgets of charpie 
should be applied in such a manner that the upper lid is gently 
stretched across the eyeball in a lateral direction, and the lids thus 
kept immovable. The two principal points of pressure should be 
at the inner and outer canthus, so that the eyeball is only pressed 
by the upper lid being stretched gently across it. 

Von Graefe 3 makes use of three different forms of compressive 
' bandages — 1, the temporary ; 2, the regular compress ; 3, the pres- 
sure compress. 

1. The temporary bandage simply consists of a knitted cotton band 

1 Charpie consists of threads of very fine linen ; the linen should be cut into 
small squares of about 3 or 4 inches in diameter, and the individual threads are 
then to be pulled out, thus forming the charpie, which should be folded into small 
pledgets. This is much cooler and more comfortable than cotton wool. 

2 A. f. 0. ix. 2 ; vide also an abridgment of this paper, by the author, in R. L. 
O. H. Rep. iv. 2. 



INTRODUCTION. 31 

about 15 inches in length and If inch in width, which is to be 
placed over the eye and fastened by a couple of tapes. For this 
purpose I think Liebreich's bandage is to be greatly preferred, but 
with the next two forms of bandage it is different, for here we can 
regulate the degree and mode of pressure desired with a nicety and 
accuracj'' not to be obtained with Liebreich's. 

2. The Regular Compress. — This bandage is about If yard long 
and 1J inch wide. Its outer two-thirds consist of fine and very 
elastic flannel, its central third of knitted cotton. The eye having 
been padded with charpie or cotton-wool, as above directed, the 
bandage is to be thus adjusted: One end is to be applied to the 
forehead just above the affected eye, and is v then to be passed to the 
opposite side of the forehead and above the ear to the back of the 
head ; the knitted portion is next carried on below the ear and 
brought upwards over the compress, the bandage being then again 
passed across the forehead and its end firmly pinned. The opposite 
eye may be closed with a strip of plaster, or, should it also require 
a compress, a separate bandage is to be applied. 

3. The pressure bandage is made of fine and very elastic flannel, 
and should be about 3J yards long and 1\ inch wide. It is intended 
to produce complete immobility of the eye, and to exert a consider- 
able degree of graduated pressure. The one end of the bandage is 
to be placed upon the cheek, at a point about midway between the 
angle of the jaw and the ear of the affected side, and the bandage 
brought up over the compress (but not applied too tightly) and 
carried across the forehead to the back of the head ; and then, pass- 
ing beneath the ear, a second turn is to ascend (somewhat more 
vertically) over the compress, pressing firmly upon the latter. The 
bandage is then again carried across the forehead to the back of the 
head, and finally brought once more over the compress, but this 
time it is not to be pulled tight. 

Baron Heurteloup's Artificial Leech. — This instrument is of the 
greatest service in the abstraction of blood in deep-seated intra- 
ocular diseases, as, for instance, in inflammations of the choroid, 
retina, and optic nerve. For, in order to relieve the intra-ocular 
circulation, it is necessary that the depletion should be rapid, and 
we find that in the inflammations of the deeper tunics of the eye, 
depletion by leeches is almost useless, whereas the effect of the 
artificial leech is very considerable. The instrument consists of a 
small sharp cylindrical drill, and of a glass exhausting tube, with 
an air-tight piston. The drill can be set so as to make the incision 
of the desired depth, and is worked by a string, on pulling which 
a rapid revolution of the drill is caused, and the skin consequently 
deeply incised. The instrument is to be applied to the temple, and 
the hair should be previously shaved off at this spot, otherwise it 
will get between the skin and the edge of the exhausting tube, and 
thus cause the admission of air. The incision should be made 
tolerably deep (the depth varying of course with the thickness of 
the skin), in order that the blood may flow freely and rapidly. 



32 INTRODUCTION. 

The air-tight piston is then to he applied over the incision, and a 
few rapid turns given, so that the skin may be somewhat sucked 
up into the tube. The blood will now flow very rapidly, and the 
screw in the piston must be moved in accordance with the flow of 
blood,.so that no vacuum exists between the plug and the column 
of blood, nor should the screw be moved roughly and too quickly, 
otherwise it may produce great pain. The glass cylinder (which 
holds about 1 oz. of blood) should be filled in from three to four 
minutes. The plug of the cylinder should be soaked in hot water 
previous to the operation, so that it may swell up and fit very 
tightly into the tube, and the edge of the latter, which is applied 
to the skin, should be greased or soaped, in order that it may fit 
closely to the skin, and prevent the entrance of air. With a little 
practice the operation may be gently yet effectually performed 
without giving much pain to the patient. Hot fomentations shoidd 
be applied afterwards, so that there may be free after-bleeding. As 
the abstraction of blood near the eye always causes considerable 
increase in the flow of blood to the part and its vicinity, the 
patient should be kept in a darkened room for the first twenty-four 
hours, until the period of reaction is passed. At first the sight 
will be a little dim and indistinct, but after thirty or thirty-six 
hours have elapsed, the beneficial effects of the depletion will 
generally be marked. 

The Eye-douche. — The best and cheapest form of this instrument 
consists of a piece of India-rubber tubing about 4£ feet in length, 
carrying a rose at one end, and at the other a curved piece of me- 
tallic pipe, which is to be suspended in a jug of water placed on a 
high shelf. The fine jet of water thrown up through the rose will 
be about 12 or 15 inches in height, and the force with which it 
plays upon the eye may be regulated by approximating or removing 
the latter from the rose. This form of eye-douche is to be preferred 
to that which is applied by means of a cup to the eye itself, as the 
jet is in this case far too strong, and often increases instead of alle- 
viating the irritation. It is to be employed night and morning, or 
oftener if the eyes feel hot and tired, for two or three minutes at a 
time. The eyelids are to be closed, and the stream of water is to 
play gently upon them. 

Mathieu's (Paris) water pulverizer, or the instrument used for 
Dr. Richardson's ether -spray, will also be found very useful and 
agreeable. 



Chapter I. 

DISEASES OE THE CON JUNCTIVA. 



1.— HYPEREMIA OF THE CONJUNCTIVA. 

We not unfrequently meet with a hypersemic condition of the 
conjunctiva, and it is of practical importance to distinguish this 
from a mild form of conjunctivitis. In the former condition we 
find, on everting the eyelids, that their lining membrane is abnor- 
mally red, and perhaps a little swollen, and traversed by well-marked 
meshes of bloodvessels, which render the Meibomian glands some- 
what indistinct. This increased redness may extend to the retro- 
tarsal fold, caruncle, semilunar fold, and even to the ocular conjunc- 
tiva, so that the white of the eye appears flushed and injected. The 
papillae of the conjunctiva may also be slightly swollen and turgid, 
which gives a somewhat rough and velvety appearance to the inside 
of the lids. The patient is generally troubled by a feeling of smart- 
ing and itching in the eye, and a heaviness and weight in the eye- 
lids, so that he experiences some difficulty in keeping them open. 
These sensations become worse in the evening, more especially in 
bright artificial light. Sometimes there is a slight tendency to 
lachrymation when the eyes are exposed to wind or a smoky atmos- 
phere, but there is no trace of any mucous discharge. 

This hypersemic condition may be produced by long-continued 
work at small objects, such as reading, engraving, microscopizing, 
more especially by strong artificial light. It is also not unfrequently 
a reflex symptom of hyperaemia of the choroid and retina. Thus, in 
very short-sighted persons affected with sclerotico-choroiditis poste- 
rior, we often notice that the conjunctiva becomes flushed if they 
persist long in reading, sewing, etc. Again, we frequently meet 
with the same thing in persons suffering from hypermetropia, who 
either do not use spectacles at all, or of insufficient power, so that 
their accommodation is strained and fatigued. 

It may also be caused by an irritating condition of the atmos- 
phere, e. g., cold wind, dust, etc. Or it may be due to mechanical 
irritants, such as a foreign body lodged under the eyelids or in the 
cornea, to inversion of the lashes, or an obstruction of the lachrymal 



The treatment of hypersemia of the conjunctiva is very simple, 
and should be chiefly directed to the removal of the cause. If it 
3 



34 DISEASES OF THE CONJUNCTIVA. 

be brought on by overwork, cessation from this must be enforced, 
and if the patient suffers from hypermetropia, this must be treated 
by the proper use of spectacles. The eye-douche or the pulverizer 
must be frequently used, and the eyelids should be bathed with an 
evaporating lotion, which greatly relieves the feeling of heaviness 
in the lids. The following lotions will be found very useful for 
this purpose: — 

1. B Sp. aether, nit, 3j ; Acet. aromat. gtt. vj ; Aq. destill. gvj. 
To be sponged over the closed eyelids and around the eyes 3 — 4 
times daily, and allowed to evaporate. 

2. R ^Etheris 3ij— 3iv; Spir. rosmar. giv. To be used in the 
same way as the above, but in smaller quantity, especially if the 
skin be very delicate and susceptible. The best astringent lotions 
are those composed of 2 — 4 grains of sulphate of zinc or acetate of 
lead, in 4 — 6 ozs. of water. A piece of folded lint saturated with 
this lotion is to be laid over the eyelids for 15 or 20 minutes several 
times a day, and a few drops may be allowed to enter the eye. 

But if the hypersemia has become chronic, these applications will 
not suffice, and it will then be necessary to apply a drop or two of 
a weak collyrium (gr. j — ij to gj of water) of sulphate of zinc or 
copper, or even of the nitrate of silver, to the conjunctiva ;' or the 
sulphate of copper or the lapis divinus 2 may be lightly applied in 
substance. The eye-douche or cold compresses should be used after 
these applications. I must here call attention to a very prevalent 
popular error, namely, that it strengthens the eyes to dip the face 
into cold water with the eyelids open. This habit is, however, to 
be condemned, as it often produces much irritation and hypersemia 
of the conjunctiva. 



2.— CATARRHAL OPHTHALMIA. 

The term "simple conjunctivitis" should, I think, be altogether 
discarded. It is, in fact, only the mildest form of catarrhal ophthal- 
mia, and hence there is no reason to make it a distinct disease. 

On everting the eyelids in a case of catarrhal ophthalmia, we notice 
that the conjunctiva is red, vascular, and swollen, so that the Mei- 
bomian glands are nearly or entirely hidden. The hypersemia com- 
mences at the tarsal portion of the conjunctiva, to which it may 
indeed remain confined in very mild cases. Generally, however, it 

1 Collyria are best applied with a camel's hair brush or the hollow part of a 
quill pen, which is not to be cut pointed (as for writing) but rounded off, a small 
hole being cut in the upper part, so that the air may enter and force out the liquid. 
The surgeon should stand in front of the patient, and, directing him to look upwards, 
raise the upper lid with the forefinger of his left hand, and depress (and slightly 
evert) the lower lid with the thumb, in this way a little pouch is formed between 
the lower lid and the eyeball, into which the drop is to be poured. The patient 
should then rub the lids well together, so that the collyrium may come in contact 
with the whole of the conjunctival surface. Instead of the quill or brush, the stop- 
per of a drop-bottle, as sold by most chemists, may be used. 

3 Lapis divinus is composed of equal parts of sulphate of copper, nitrate of potass 
and alum, which ingredients are to be moulded into sticks. 



CATARRHAL OPHTHALMIA. 



85 




soon extends to the retro-tarsal fold, caruncle, semilunar fold, and 
ocular conjunctiva, reaching perhaps quite up to the edge of the 
cornea. As the disease subsides, the vascularity retraces its steps 
in the reverse direction. It is important to distinguish the vascu- 
larity of the ocular conjunctiva from 
that of the subconjunctival tissue. 1 The 
former is characterized by a superficial 
network of vessels of a brick-red or 
scarlet color, which run up to the edge 
of the cornea, and are freely movable 
upon the sclerotic. [Fig. 13.] The 
meshes of this network are coarse and 
large, more especially towards the re- 
gion of the retro-tarsal fold. On and 
between them are often noticed coarse 
red patches of extravasated blood, par- 
ticularly near the cornea. But these 
effusions are also seen on the palpebral 
conjunctiva and retro-tarsal fold. If 
the ocular conjunctiva is alone impli- 
cated, the white sclerotic can be seen 
shining through the vascular meshes. 
But it is different if the subconjunctival- tissue is also injected, for 
we then notice fine, parallel vessels of a rosy tint, radiating towards 
the cornea, around which they form a pink zone. These vessels 
are not movable upon the sclerotic. 

The eyelids are generally somewhat swollen and red, and their 
temperature is perhaps slightly increased ; but none of these symp- 
toms are so marked as in purulent ophthalmia. Occasionally, the 
cedema of the eyelids is so considerable that the upper lid hangs 
down in a massive fold, and overlaps the lower. The edges of the 
lids are usually somewhat red and swollen, and at a later stage they 
often become sore and excoriated from the discharge and the altered 
secretion of the Meibomian glands. Indeed, this irritation may in. 
time give rise to marginal blepharitis. 

The degree of swelling of the lids does not, however, necessarily 
correspond, to the intensity of the disease, or the l'edness of the con- 
junctiva. Thus, in feeble subjects we sometimes find that there is 
great cedema of the lids, leading us to suspect a severe form of the 
disease, and yet, on opening the eye, we are surprised to find but 
slight injection of the palpebral and ocular conjunctiva, and but 

1 We may distinguish three kinds of vascularity on the eyeball : 1. The conjunc- 
tival vessels, which are brick-red, large-meshed, and freely movable. They con- 
sist both of veins and arteries. 2. The subconjunctival vessels, which are of a pink, 
rosy tint, their meshes being smaller, and the vessels radiating in a parallel direc- 
tion towards the edge of the cornea, around which they form a rosy zone ; these 
vessels are chiefly venous. 3. The sclerotic vessels, which do not appear in the 
form of distinct individual vessels, but as small ill-defined red patches, which lend 
a bluish-red blush to the surface of the sclerotic. For further information as to the 
bloodvessels of the eye, I must refer the reader to Leber's important researches,. 
A. f. 0. xi, 1, 1 ; and also to those of Donders, Klin. Monatsblat. 1864. 



36 DISEASES OF THE CONJUNCTIVA. 

little, if any, discharge. In such cases we should examine as to the 
existence of an hordeolum, or whether the patient has been stung 
on the lid by an insect. 

In the severer cases of catarrhal ophthalmia, we find that the 
conjunctiva becomes very swollen, more especially in the region of 
the retro-tarsal fold, so that, on considerable eversion of the eyelids, 
it springs into view in the form of one or more thick red girdles 
encircling the eyeball. The caruncle and semilunar fold are also 
swollen, and assume a dark red and fleshy appearance. At an early 
stage of the affection, the swelling of the conjunctiva is firm, and 
lends a peculiar lustrous and glistening appearance to the inner sur- 
face of the lids ; but later it becomes more flaccid and soft, and falls 
more readily into folds. The papillae of the conjunctiva generally 
become swollen and turgid, often to a considerable degree, so that 
they give a rough, velvety, and so-called " granular" appearance' to 
the conjunctiva. 1 In severe cases, especially in old decrepit persons, 
and after the long-continued use of cold applications, the ocular 
conjunctiva may also become swollen (chemosis), which is due to a 
serous, or perhaps even plastic, infiltration of the conjunctiva and 
subconjunctival tissue. In the majority of cases, however, the che- 
mosis is but very slight. 

The discharge varies in quantity and quality, according to the 
stage and intensity of the affection. In the early stages, there is 
generally only an increased secretion of tears, but the discharge soon 
becomes more opaque and stringy, and of a yellowish-red tinge, 
consisting chiefly of albumen and broken-down epithelial cells. As 
the disease advances, and the inflammatory symptoms increase in 
severity, the discharge becomes more copious and of a muco-puru- 
lent character, the pus cells being suspended in the mucus. It then 
also assumes a light yellow color, and a thicker and more creamy 
consistence. In very mild cases it is often so slight in quantity that 
it might easily escape detection. Perhaps it is only on very con- 
siderable eversion of the lids, that a thin yellow string of matter is 
observed to be imbedded and almost hidden in the folds of the con- 
junctiva, or collected in the form of a small yellow bead at the angle 
of the eye. The lashes are generally found to be somewhat glued 
together in the morning by the discharge, and the altered and in- 
creased secretion of the Meibomian glands. 

There is generally very little pain in catarrhal ophthalmia. The 
patient only complains of a feeling of heat and itching in the lids, 
which causes him to rub them frequently. These sensations in- 
crease towards night, and manifest themselves especially during 
reading or writing by artificial light, or in a crowded and smoky 
room. The eyelids feel stiff and heavy, so that it is difficult to 

1 In using the term "granular" for this appearance of the conjunctiva, I must 
strongly insist upon the great necessity of not confounding this condition with that 
of true granular life, which is but too often done, and which has led to very great 
confusion, not only in the diagnosis, but also in the treatment recommended for 
these affections. In the former case, the granular appearance is simply due to the 
infiltrated and turgid condition of the papilla?, whereas the true granulations are a 
new formation of a perfectly different character. 



CATARRHAL OPHTHALMIA. 37 

open them, this is especially the case if the lids are rather tight 
and press upon the globe. One of the most characteristic symp- 
toms is the sensation as if a foreign body, such as sand, grit, or 
finely-powdered glass, were lodged under the lids. This is evidently 
due, as was pointed out by Mackenzie, to the friction of the swollen 
papillae against the ocular conjunctiva. This sensation should, 
however, remind us of the fact that the symptoms of catarrhal 
ophthalmia, viz., conjunctival and subconjunctival injection, lachry- 
mation, pain, etc., may be produced by a foreign body, and the 
inner surface of both lids, as well as the cornea, should therefore 
be carefully examined, in order that we may ascertain whether a 
foreign body be present or not. 

There is generally only a slight degree of photophobia. If it is 
severe, and accompanied by much lachrymation, subconjunctival 
injection, and considerable pain in and around the eye, more 
particularly over the brow and down the side of the nose (ciliary 
neuralgia), it is a sign that there is much irritation of the ciliary 
nerves. 

Vision is only in so far affected, that objects may appear somewhat 
hazy and indistinct, as if seen through ground glass, which is due 
to the presence of a little of the discharge upon the cornea. The 
patients also notice muscse volitantes in the shape of strings of fine 
beads floating through the field of vision, these are produced by 
mucus and little flakes of epithelium being washed over the cornea 
by the movements of the eyelids. For the same reason, the flame 
of a candle often appears to be surrounded by a colored ring, which, 
however, also disappears when the lids are rubbed. I need hardly 
point out that this should not be confounded with the luminous 
ring round a flame, which is one of the premonitory symptoms of 
glaucoma. 

Catarrhal ophthalmia may be caused by sudden changes in the 
atmosphere, by exposure to cold, draught, and wet, or to great heat 
and glare, as, for instance, from a blacksmith's forge, or a large 
cooking fire. Long confinement in hot, smoky, crowded, and ill- 
ventilated rooms may likewise produce it, as also excessive use of 
the eyes, especially by artificial light. Or it may show itself in 
conjunction with, and be a part symptom of, the affections of the 
mucous membrane of the nose or respiratory organs. As a con- 
tinuation of the common integument, the conjunctiva may, more- 
over, become affected in the acute exanthemata, as in smallpox, 
scarlatina, and measles, also in erysipelas, herpes zoster, and eczema 
of the face. It may suffer consecutively in affections of the eyelids, 
as for instance in ectropion or distich iasis, or in those of the 
lachrymal apparatus. Indeed epiphora, dependent upon some im- 
pediment to the free efflux of the tears, is a not unfrequent cause 
of obstinate and chronic inflammation of the conjunctiva, which 
readily disappears as soon as the lachrymal affection is cured. 
Undetected foreign bodies, or injuries from mechanical or chemical 
irritants, may also give rise to conjunctivitis. 

Finally, it may be produced by contagion, more especially if the 



38 DISEASES OP THE CONJUNCTIVA. - 

disease is at all severe, if the swelling extends to the retro-tarsal 
fold of the upper lid, and the discharge is of a muco-purulent 
character. It almost always reproduces catarrhal ophthalmia and 
only in rare cases gives rise to the purulent or diphtheritic form. 

The prognosis of catarrhal ophthalmia is favorable, for the affec- 
tion is very amenable to treatment. The milder forms generally 
run their course in a few days, the more severe in two or three 
weeks. The cornea becomes but seldom implicated, and even if 
ulcers should form upon it, they are generally quite superficial and 
peripheral, so that at the worst they only give rise to a slight 
opacity. Only in very severe cases and under very injudicious 
treatment do the cornea and irisl participate to any dangerous 
extent. 

If the affection is neglected, it may become chronic and prove 
very obstinate and intractable, more especially in old persons. The 
conjunctiva becomes flaccid and rough, and this may give rise to 
superficial corneitis, or ectropion, particularly of the lower lid. 

The treatment must vary according to the stage and the severity 
of the disease. If the eye is very irritable, and there is much 
photophobia, lachrymation, and ciliary neuralgia, accompanied by 
conjunctival and marked subconjunctival injection, astringent 
lotions should be carefully avoided, as they would increase the 
irritability, or might even set up inflammation of the cornea or 
iris. In such cases, the lids should be well everted, and a careful 
examination made as to the presence of a foreign body beneath 
them, or upon the cornea. If none is detected, the condition of ' 
the palpebral and ocular conjunctiva and of the cornea and iris 
should next be ascertained, as these symptoms of irritation may 
be due to phlyctenular ophthalmia, or to a commencing inflamma- 
tion of the cornea or iris. In this condition of the eye, it is often 
impossible to decide whether it is simply a case of commencing 
catarrhal ophthalmia accompanied by unusually severe symptoms 
of ciliary irritation, or whether it is a case of incipient corneitis 
or iritis. It is, therefore, always the wisest plan to leave the ques- 
tion of diagnosis open, until the real character of the affection 
becomes more pronounced, and to endeavor to alleviate the symp- 
toms of irritation by soothing applications (such as atropine and 
warm fomentations). By so doing, we guard ourselves against 
committing, perhaps, a serious error in treatment. For if it should 
turn out to be a case of catarrhal ophthalmia, astringents may be 
employed as soon as the symptoms of irritation have somewhat 
subsided, and the discharge has assumed a muco-purulent character; 
if, on the other hand, it should prove to be a case of corneitis or 
iritis, the treatment has been most appropriate and judicious, 
whereas the use of astringents, more especially the more powerful 
ones, would have been very injurious. 

The patient should be warned to guard his eyes against exposure 
to wet or cold ; and to abstain from all reading, etc., more especially 
by artificial light. 

In order to relieve the ciliary neuralgia, hot poppy fomentations 



CATARRHAL OPHTHALMIA. 39 

should be applied to the eye; but if the patient should be of a 
rheumatic habit, the moisture may produce considerable oedema of 
the lids, and hot dry flannels are therefore to be preferred. 

A solution of atropine (gr. ij to gj of water) should be dropped 
into the eyes two or three times a day, and the following compound 
belladonna ointment should be rubbed over the forehead : — 

R Extract belladonnse gr. x ; Hydrarg. ammon. chlorid. gr. v ; 
Adip. 3j. M. A portion of this is to be rubbed over the forehead 
three or four times daily, and should be covered by a piece of thin 
tissue paper, so as to prevent its drying and becoming hard. It 
should not be washed off until it is time for its re-application. In 
the course of two or three days a slight papular eruption will 
appear, when the ointment is to be discontinued. 

When the acute symptoms of irritation have subsided, and those 
of catarrhal ophthalmia — more especially a muco-purulent discharge 
— begin to show themselves, astringents must be applied. In the 
milder cases, in which there is not much conjunctival redness, and 
the discharge is chiefly of a mucous character, lodging in the form 
of thin, yellowish stringy flakes in the retro-tarsal fold, or the 
angles of the eye, a solution of sulphate of zine or copper (1 or 2 
grains to the ounce of distilled water) should be dropped into the 
eye two or three times daily. If the bloodvessels are much dilated, 
and the conjunctiva relaxed and flaccid, a solution of tannin (gr. 
iv — viij to gj of water) is to be preferred. I have also found much 
benefit from the chloride of zinc (gr. ss — j to gj) which is strongly 
recommended by Mr. Critchett. 

But if the inflammation is severe, if the discharge is copious, 
thick, and creamy, these remedies will no longer suffice, and we 
must have recourse to nitrate of silver, the strength of the solution 
varying according to the amount and thickness of the discharge. 
For general purposes a solution of 2 or 3 grains to the ounce will 
be found the best. A large drop of this should be applied with a 
camel's hair brush or a quill to the inside of the lower eyelid three 
or four times a day. The lids should then be rubbed with the 
finger, so that the solution may come in contact with the whole of 
the conjunctiva. The feeling of grit and sand in the eye as well 
as the lachrymation are much relieved, and will disappear for five 
or six hours. On their reappearance, the collyrium should be again 
applied. It may, however, be necessary to apply a still stronger 
solution (gr. iv^-yj to ij) if the discharge is very copious and thick, 
and if the affection has lasted for some time, or the mitigated 
nitrate of silver should be applied in substance, vide p. 51. Before 
the collyrium is applied, the discharge must be removed by the 
injection of lukewarm water beneath the lids. This renders the 
action of the collyrium far more efficacious. After each instilla- 
tion of the astringent collyria, cold water compresses should be 
applied to the lids for the space of from quarter to half an hour, 
being changed as soon as they become at all warm. This will give 
great relief to the patient, and subdue the pain and irritation pro- 
duced by the lotion. 



40 DISEASES OP THE CONJUNCTIVA. . 

Lukewarm water should be injected between tbe lids every two 
or three hours, so as to wash away the discharge. Or the following 
lotion recommended by Mackenzie may be employed with advan- 
tage for this purpose. B Hydrag. bichlorid. gr. j ; Ammonise 
muriat. gr. vj ; Aq. destill. Syj. Misce. A tablespoonful of this 
lotion is to be mixed with a tablespoonful of hot water. In mild 
cases the eyes should be fomented with it three or four times daily, 
a little being permitted to enter the eye. In severer cases it should 
be injected over the whole conjunctiva. 

A little simple cerate orunscented cold cream is to be applied to 
the edges of the lids to prevent their sticking. If crusts have 
formed upon the lashes, they are to be soaked with warm water, 
and then carefully removed so as not to produce any excoriation. 
If the edges or angles of the lids are sore and excoriated, the red 
precipitate ointment (gr. j — ij to the drachm of lard) is to be 
applied night and morning, or the weak nitrate of mercury oint- - 
ment may be used. 

The attendants must be warned that the discharge in catarrhal 
ophthalmia is contagious, and that the sponges, towels, etc., used 
for the patient must be carefully kept apart, and not employed for 
any other purpose. Some authors have expressed a doubt as to 
the contagiousness of catarrhal ophthalmia, but in out-patient 
practice we have very frequent opportunities of seeing several 
members of the same family affected consecutively with the dis- 
ease. Constitutional treatment will hardly be required ; the bowels 
should be kept freely open, and if the patient is feeble and out of 
health, tonics should be administered. 



3— PURULENT OPHTHALMIA. 

(Syn. Egyptian ophthalmia, contagious ophthalmia, military 
ophthalmia.) 

We cannot draw a sharp line of demarcation between acute 
catarrhal, and purulent ophthalmia. The latter may indeed be 
regarded as a more severe form of catarrhal ophthalmia, in which 
all the symptoms of this affection are intensified in degree. The 
lids are more cedematous, hot, and red, the palpebral and ocular 
conjunctiva more injected and swollen, and the papilla? more turgid 
and prominent. The chemosis is also more considerable, and the 
discharge is thicker, more copious, and more contagious. The 
inflammation is, moreover, not confined to the conjunctiva, but 
extends deeper, and involves also the sub-conjunctival tissue. So 
that there is not only a secretion of muco-purulent discharge upon 
the free surface of the conjunctiva, but also an infiltration of sero- 
plastic lymph into the substance of this membrane. The cornea is, 
moreover, far more frequently and more seriously implicated than 
in catarrhal ophthalmia. 

At the commencement, the patient experiences a sensation of 
heat and itching in the eye, as if a foreign body, more especially 



PUBULENT OPHTHALMIA. 



41 



sand or grit, were lodged beneath the eyelids. The edges of the 
latter become slightly glued together, and small beads of matter 
collect and harden on the lashes and at the corners of the eye. On 
eversion of the lids, their lining membrane is found- to be very 
vascular, swollen, and of a uniform redness, so that the Meibomian 
glands can no longer be distinguished. The retro-tarsal fold, the 
caruncle, semilunar fold, and ocular conjunctiva are also abnormally 
red and swollen. The eyelids are red, glistening, and perhaps some- 
what puffy. At first, there is only considerable lachrymation, but 
the discharge soon assumes a muco-purulent character, having 
yellow flakes of pus and broken-down epithelial cells suspended 
in it. 

Up to this point, all these symptoms are only those of catarrhal 
ophthalmia. But as the disease advances, they soon become more 
severe in character. The patient often experiences great pain in 
and around the eye, which may even extend to the corresponding 
half of the head, especially if the inflammation be of a sthenic cha- 
racter, in which case marked febrile symptoms may also present 
themselves. Generally, the pain diminishes as soon as the discharge 
becomes purulent. It may, however, again increase in severity if 
the cornea becomes affected, and especially if the iris or other tis- 
sues of the globe should become 
involved in the inflammation. In [ F 'g- 14 - 

general inflammation of the eye- 
ball (panophthalmitis) the pain is 
often excruciating. 

The lachrymation and photopho- 
bia increase, the lids become very 
swollen, so that the upper hangs 
down in a thick heavy fold, and 
they can only be opened or everted 
with difficulty. [Fig. 14.] They 
are red, glistening, and oedematous, 
and, if deeply pressed, somewhat 
tender. Their temperature, though 
markedly increased, never reaches 

a very high degree, and this, to- After Dairympie.] 

gether with the absence of tender- 
ness, is of importance in the differential diagnosis between purulent 
and diphtheritic ophthalmia. The conjunctiva becomes vascular 
and swollen, and patches of effused blood are noticed both on its 
palpebral and ocular portion. The papillse are very turgid and 
prominent, giving a rough and villous appearance to the inside of 
the lids. As they increase in size they become flattened at the 
sides, from being pressed against each other, and they appear ar- 
ranged in rows without a distinct base. The prominence may be 
so considerable that they assume the appearance of cauliflower 
excrescences. They often bleed freely on the slightest touch, as 
their epithelial covering is very thin and easily shed. The retro- 
tarsal fold is much swollen, and, on eversion of the lids, springs into 





Shows the swollen and chemotie condition of 
the conjunctiva of an eye in which the disease 
has existed four or five days. After Dalrymple.] 



DISEASES OF THE CONJUNCTIVA. 

[Fig. 15. view in the form of thick, red, 

_-^ fleshy girdles, which encircle 

J Sj^Ji the eyeball. The ocular 

^fj^J ! Jfcjsjr. jimetiva becomes very vaseu- 

^^ ^fe^ lar, and a serous or even plas- 

tic effusion takes place into 
it, and the sub-conjunctival 
tissue. [Fig. 15.] This che- 
mosis is far more marked than 
in catarrhal ophthalmia, and 
may be so considerable as to 
rise like a high, red, semi- 
transparent mound round the 
cornea, overlapping its edges 
more or less considerably, and 
even perhaps protruding be- 
tween the lids. The chemosis 
is most prominent at the 
outer and inner side of the 
cornea, at the triangular 
spaces opposite the palpebral 
aperture ; for the pressure of 
the lids keeps down the che- 
motie swelling above and be- 
low. On account of the great swelling and weight of the eyelids, 
and the great chemosis, the vessels supplying the cornea become 
much compressed, and its nutrition proportionately impaired ; and 
this explains the great tendency to ulceration and suppuration of 
the cornea in severe purulent ophthalmia. For the idea that the 
irritating and noxious character of the discharge produces the 
affection of the cornea is erroneous. 

As the disease advances, the discharge increases in quantity, 
becomes more opaque, thick, and creamy, and, on account of its 
admixture with blood, frequently assumes a reddish-yellow tint. 
It is often so considerable in quantity that it wells out from between 
the eyelids when these are opened, and flows down over the cheek ; 
the lashes become clogged with it, and glued together into little 
bundles. It collects in the retro-tarsal fold and on the surface of 
the cornea in the hollow formed by the chemosis, and this appear- 
ance may easily be mistaken by a superficial observer for suppura- 
tion of the cornea. The discharge should, therefore, always be 
wiped away from the cornea before any opinion is formed as to the 
condition of the latter. On cleansing away the matter from the 
surface of the palpebral conjunctiva, we notice that the latter looks 
red, glistening, villous, and succulent, which enables us at a glance 
to distinguish the disease from diphtheritic conjunctivitis. Some- 
times, however, the discharge is more tenacious and clings to the 
surface of the conjunctiva like a thin membrane, so that it cannot 
be easily wiped away, but requires to be stripped oft", when it comes 
off in the form of thin flakes. But on its removal, we find that 



PURULENT OPHTHALMIA. 43 

the membrane was quite superficial, and that the appearance of the 
conjunctiva beneath is the same as that described above. Hence 
it is erroneous to call this " diphtheritic conjunctivitis," simply 
because the discharge is more tenacious and comes off in flakes, for 
the symptoms of true diphtheritic ophthalmia are not only very 
different, but demand a very different course of treatment; but 
there can be no objection to terming it "membranous ophthalmia." 
We sometimes, however, meet with mixed forms of purulent and 
diphtheritic ophthalmia. 

The chief danger in purulent ophthalmia is the implication of 
the cornea. Any cloudiness of the latter must, therefore, be 
always regarded as an untoward symptom, more especially if it 
already shows itself at an early stage of the disease, and if there 
is any tendency to a diphtheritic character in the ophthalmia. At 
a later period it is less to be feared. The appearance of the cornea 
must be carefully watched from day to day, and in severe cases its 
condition should be examined, if possible, at the interval of a few 
hours. Implication of the cornea is especially likely to occur if 
the inflammation is very severe, the temperature of the lids much 
increased, the chemosis considerable and firm, and accompanied by 
great photophobia, lachrymation, and ciliary neuralgia. The pain 
is generally intermittent, and often very severe, especially towards 
night ; it may extend deep into the orbit and over the correspond- 
ing side of the head and face. On examining the condition of the 
cornea, we may then perhaps discover small phlyctenule or infil- 
trations at its edge or upon its surface, which soon pass over into 
ulcers. Sometimes there is a serous infiltration (cedema) into the 
cornea, which may remain confined to the periphery, giving it a 
slightly steamy or clouded appearance. If this opacity is consider- 
able, and extends over the centre of the cornea, the sight may be 
greatly impaired, or a circumscribed light gray infiltration may 
show itself at one portion of the cornea and disappear again as the 
ophthalmia subsides, or it may become more dense and assume a 
yellow tinge. Generally, the infiltration soon changes into an 
ulcer, which may, in favorable cases, remain superficial, and ulti- 
mately leave only a very slight, or even no opacity of the cornea. 
But if the infiltration or ulcer is of considerable size and rather 
deep, a dense opacity may remain behind, and greatly impair the 
sight if it be situated in the centre of the cornea. The ulcer, in- 
stead of remaining superficial, may, however, rapidly increase in 
circumference and depth, and soon lead to extensive perforation of 
the cornea, accompanied by prolapse of the iris, escape of the lens 
and perhaps a certain quantity of vitreous humor, and be followed 
probably by the formation of a considerable staphyloma. 

When tne cornea gives way, the patient experiences a sudden 
remission of the violent pain, accompanied by a gush of fluid oyer 
the cheek. If the ulcer is large, the cornea, on account of being 
thinned and softened at this point, may become somewhat bulged 
forward before perforation occurs. The dangerous character of the 



44 DISEASES OF THE CONJUNCTIVA. 

ulcer of course increases with its extent, as the perforation will be 
proportionate in size. 

Sometimes, several infiltrations are formed near to each other 
and then coalesce, thus giving rise to one large ulcer. In many 
cases the perforation, if it be but of limited extent, is- the best 
thing that can occur, for the ulcer, instead of increasing in circum- 
ference, then begins at once to heal. 

Perforation of the cornea may give rise to the following compli- 
cations : 1. Prolapse of the iris ; 2. Anterior synechia ; 3. Central 
capsular cataract; 4. Displacement or obliteration of the pupil; 
5. Anterior staphyloma. For further information upon this sub- 
ject, I must refer the reader to the chapter on ulcers of the cornea. 

If the perforation of the cornea is small, a little portion of the 
iris will fall against it ; when the aqueous humor escapes, lymph 
will be effused at the bottom of the ulcer, and the iris will become 
adherent at this point to the cornea, giving rise to an anterior 
synechia. The pupil will be dragged towards the adhesion and 
more or less displaced ; or it may be partially or wholly implicated 
in it. If the perforation was extremely small (such as would be 
produced by a fine needle) the re-accumulation of the aqueous 
humor may tear through any little adhesion that has taken place 
between the iris and cornea, and no anterior synechia will be left. 
When the perforation occurs at the centre of the cornea, the lens 
will come in contact with the bottom of the ulcer, and a central 
anterior capsular cataract may be formed. If the cornea gives way 
to a greater extent, a knuckle of iris may be pushed into the ulcer 
and cause a prolapse of the iris, which may increase to a very con- 
siderable size from the aqueous humor collecting within it and 
swelling it out. A small protrusion of this kind has been termed 
a myocephalon. Or the lens may escape together with some of the 
vitreous humor, if the rupture of the cornea is large, and then the 
eyeball may become atrophied. Or the iris falls into the gap, 
becomes adherent to the cornea and covered with lymph, which 
assumes a cicatricial character, and yielding gradually to the intra- 
ocular pressure, becomes more and more prominent, and a partial 
pr total staphyloma results. 

A very dangerous kind of ulcer is that which makes its appear- 
ance in the form of a small crescentic ulcer near the edge of the 
cornea (generally the lower), looking as if it had been scratched 
by a finger nail. Its edges soon become infiltrated, and assume a 
yellow tint. It increases in depth, and rapidly extends further 
and further round the cornea, until it may give rise to a very con- 
siderable perforation or slough of the latter. On account of its 
being situated so closely to the edge of the cornea, this form of 
ulcer is often hidden by the chemosis and thus easily overlooked 
at the outset. 

In very severe cases of purulent ophthalmia with intense inflam- 
matory symptoms, sloughing of a great portion or even of the 
whole of the cornea may take place within a few hours. The 
cornea loses its transparency, becomes of a grayish-white color, 



PURULENT OPHTHALMIA. 45 

which soon passes into a yellow tint, and looks shrivelled and 
quite opaque. It soon yields to the intra-ocular pressure, gives way, 
and the eyeball becomes atrophied. 

Iritis may supervene when the ulceration has extended to the 
deeper layers of the cornea, or when perforation has occurred. If 
severe, it generally gives rise to great ciliary neuralgia, photophobia, 
and lachrymation. If a portion of the cornea remains sufficiently 
clear to permit of our seeing the iris, we find the latter discolored, 
and the pupil contracted, irregular, and perhaps blocked up with 
lymph, or there may be pus in the anterior chamber. The inflam- 
mation may extend from the iris to the other tissues of the eye, 
and general inflammation of the eyeball (panophthalmitis) set in, 
accompanied by excruciating pain. Pannus occurs but seldom in 
acute purulent ophthalmia, and only in cases where the papillte 
have been much swollen from the very commencement of the dis- 
ease, and from their rubbing against the cornea have induced a 
superficial vascular corneitis. It is more frequently met with in 
chronic ophthalmia. It is an interesting circumstance, that if the 
cornea has been suffering from pannus before the attack of purulent 
ophthalmia, there is far less danger of its ulcerating or suppurating 
than if it is quite transparent. This important fact has been utilized 
in the treatment by inoculation of pannus dependent upon granular 
lids. 

Purulent ophthalmia generally runs its course in three or four 
weeks. It may, however, become chronic and last for many 
months or even years, and prove very obstinate. This is especially 
the case if the papillae remain swollen and prominent, for by their 
constant friction against the cornea, pannus is but too often pro- 
duced. The relaxed condition of the conjunctiva may also give 
rise to ectropion, or this may be produced by the lids having 
become everted during the progress of the disease, and not having 
been properly replaced. 

Causes. — Purulent ophthalmia may become developed from an 
acute catarrhal ophthalmia, by the symptoms of the latter in- 
creasing in severity, either through a continuation of the original 
cause, through neglect, or through a mistaken course of treatment. 
The same causes which may give rise to catarrhal ophthalmia, viz., 
exposure to cold or draught, great glare, etc., may also produce the 
purulent form. We sometimes find that it occurs epidemically, 
and that mild irritants, which would at other times only have 
caused a simple catarrhal conjunctivitis, now produce purulent 
ophthalmia. An unhealthy locality, a vitiated atmosphere, crowded 
and badly ventilated rooms, exposure to great heat or cold, dust, 
and glare, intensify the character of the epidemic. Some of these 
causes are frequently met with in places where many persons are 
collected together, as in workhouses, foundling hospitals, and large 
barracks. If purulent or even catarrhal ophthalmia once breaks 
out in such establishments, it is often very difficult to arrest it 
before it has spread widely amongst the inmates and committed 
great ravages. If soldiers on their march or in camp are exposed 



46 DISEASES OF THE CONJUNCTIVA. 

to great heat and glare, and to hot winds carrying before them 
clouds of sand and dust, as occurs in India or Egypt, ophthalmia 
will soon show itself amongst them. Hence the terms military 
and Egyptian ophthalmia. These names should, however, be 
abandoned, for this affection shows no special characteristics war- 
ranting its being classed as a disease sui generis. The epidemic is 
in such cases generally one of purulent ophthalmia, but sometimes 
it may assume the character of severe catarrhal or granular con- 
junctivitis. Or these affections may pass one into the other, or 
exist side by side in the same army. This being so, we can easily 
understand how such various, and often conflicting and confused 
accounts have been given of the character, the severity, and the 
contagiousness of the so-called military ophthalmia. 

Contagion is the most frequent cause, as the contagious power of 
the discharge is often very great. This varies, however, according 
to the severity and stage of the disease. Piringer, 1 who made a 
great number of valuable and interesting experiments to test the 
contagious power of the discharge, found that during the earliest 
stage, and also in chronic cases, in which the discharge is thin, 
watery, and transparent, it is hardly, if at all, contagious. But it 
becomes slightly so when, though still watery, it assumes a some- 
what muco-purulent character, and then it generally reproduces a 
mild form of the disease. The contagiousness increases in propor- 
tion to the intensity of the affection, and the purulent nature of 
the discharge. According to the same authority, the discharge of 
a severe purulent ophthalmia, if applied to a healthy conjuetiva, 
may reproduce the disease in from 6 — 12 hours ; that from a 
moderately severe form in from 12 — 36 ; the mild, in 60 — 70 ; and 
that from chronic ophthalmia in, 72 — 96 hours. It is of the greatest 
practical importance to remember that the discharge from purulent 
ophthalmia does not always reproduce the purulent form, but may 
give rise to catarrhal, granular, or even diphtheritic conjuncti- 
vitis — just as the discharge from catarrhal, diphtheritic, and acute 
granular ophthalmia may produce purulent ophthalmia. The 
special form of conjunctivitis which may arise will depend upon 
atmospherical, local, and constitutional causes, and also upon the 
age of the patient. Thus Von Graefe states 2 that in Berlin the 
matter from ophthalmia neonatorum, when applied to the eyes of 
children of two or three years of age, generally produces diph- 
theritic conjunctivitis, whereas when applied to adults it mostly 
gives rise to purulent or sometimes to granular ophthalmia. 

Healthy eyes are more rapidly and severely affected by the inocu- 
lation of contagious matter than those suffering from vascular forms 
of eorneitis, more especially pannus. Repeated inoculation di- 
minishes the contagious power of the discharge. This is also di- 
minished by diluting the latter with water, it being altogether lost 
when it is diluted with about one hundred parts of water. Gonor- 

1 Piringer "Die Blennorhoe irn Mensclienauge," Gratz, 1841. 

2 "Deutsche Klinik," 1864, p. 79. 



PURULENT OPHTHALMIA. 47 

rhceal and vaginal discharges may also produce purulent ophthalmia. 
It appears certain that the air is often a carrier of the contagion, 
especially if many persons suffering from severe purulent ophthalmia 
are crowded together in one room, and this is perhaps small and 
ill ventilated. Von Graefe thinks that in such cases the propaga- 
tion is partly caused by the suspension of the constituents of the > 
discharge in the atmosphere, and partly by the air expired from the 
lungs, from the discharge passing down the lachrymal passages into 
the nose — just the same, in fact, as what occurs in common nasal 
catarrh, the contagious nature of which depends chiefly upon the 
expired air. 

The prognosis which may be given in a case of purulent ophthalmia 
will depend upon the stage and severity of the disease, and also upon 
the prevailing character of the epidemic, should such exist. It may 
be favorable, if the affection is of a mild muco-purulent character 
and is due to spontaneous causes ; or, having been produced by con- 
tagion, if the inoculating matter was mild and chiefly mucous in 
character; also, if the redness and swelling of the eyelids and con- 
junctiva are but slight ; if the inflammation is chiefly confined to 
the palpebral conjunctiva, or, should it extend to the ocular, if the 
chemosis is serous and soft, not plastic and hard ; if the discharge 
is thin and scant, the cornea unaffected, the character of the epi- 
demic mild, without any tendency to the diphtheritic form of con- 
junctivitis. We must, on the other hand, be extremely guarded in 
our prognosis, or even form an unfavorable one, if the inflammation 
is very intense, the chemosis hard and lardaeeous, and so consider- 
able as completely to surround the cornea and overlap it ; if there is 
any ulceration of the cornea, especially if this be considerable in 
extent, and occurs early in the disease ; if the inflammation shows 
a diphtheritic character. 

Treatment. — If the attack is severe, the patient should be confined 
to a darkened room, or even to his bed. The room must, however, 
be well ventilated, and plenty of fresh air be admitted, particularly 
if it is occupied by several patients. Those who have the disease in 
a severe form should, if possible, be separated from the milder cases. 
I need hardly point out that in barracks, unions, schools, etc., the 
healthy inmates should be strictly kept apart from those who are 
suffering from ophthalmia. Their eyes should, moreover be exam- 
ined every day, in order that the first symptoms of the disease 
may be detected. The patients and attendants should be made 
aware of the contagious character of the disease, which continues 
as long as the discharge remains opaque and mucous. Special care 
must be taken that the sponges, towels, water, etc., which are em- 
ployed for the patients are not used by others. To guard them 
against the risk of contagion, the medical attendants and nurses 
should wear the curved blue eye protectors, more especially whilst 
applying the collyria or syringing out the eyes, as a little of the mat- 
ter may otherwise be easily splashed into their eyes. If, by accident, 
any of the discharge should have got into a healthy eye, lukewarm 
water should be at once injected under the lids so as to wash it 



48 DISEASES OF THE CONJUNCTIVA. 

away, and then a drop of a weak solution (2 grains to the ounce of 
water) of the nitrate of silver or sulphate of zinc should be applied 
to the conjunctiva. If only one eye is affected with purulent 
ophthalmia, the other must be at once, without loss of time, herme- 
tically closed. The common compress bandage will not suffice for 
this purpose, for the discharge might soak through, especially dur- 
ing the night, when it may run over the bridge of the nose from 
the affected to the healthy eye. The best protection is the follow- 
ing compress, recommended by Von Graefe. A pad of charpie or 
cotton-wool should be applied to the eyelids and covered by diachylon 
plaster, which is to be fixed down by collodion, so as to completely 
exclude the air. This compress should be removed twice daily, and 
the eye cleansed and carefully examined. If there is any redness 
or swelling of the conjunctiva, or any discharge, the pad should be 
discontinued, although in some cases the continuance of the firm 
pressure appears to cut short the attack. A drop of a weak solu- 
tion of nitrate of silver or sulphate of zinc should be at once ap- 
plied. Ice compresses may also be applied to the eyelids, as -they, 
according to Piringer, will often cut short the attack. 

There is generally not much constitutional disturbance, except 
the disease is severe, in which case, more especially in gonorrhceal 
ophthalmia, it is often accompanied by marked febrile symptoms. 
If the tongue is foul and loaded, a brisk purgative should be adminis- 
tered, and the bowels be kept well opened. If the patient is ple- 
thoric and feverish, cooling salines must be prescribed, and the diet 
be kept low. Formerly the depletory plan of treatment was carried 
to great excess, and venesection employed to such an extent that we 
read of cases in which the patient was bled " as long as the blood 
could be got from the arm." (Wardrop.) Now, however, this course 
of treatment has fortunately almost completely exploded, and vene- 
section is hardly ever employed. Indeed, we not unfrequently find 
that patients suffering from purulent ophthalmia are of a weakly 
and cachectic habit, in whom such a line of treatment would be 
most injudicious and. injurious. In all such cases tonics, especially 
quinine and steel with perhaps some ammonia, should be freely 
administered, the patients being at the same time put upon a good, 
nourishing, and easily digestible diet, with meat once or twice a 
day, and if necessary, they may even be allowed a moderate quan- 
tity of stimulants. In this we must, however, be guided by indi- 
vidual considerations. If the patient is restless and sleepless, a 
narcotic should be given at night, as it is a great relief if he can 
obtain a good night's rest. 

The greatest attention must be paid to the local treatment. The 
eye should be frequently cleansed of the discharge. The eyelids 
being opened, a small stream of lukewarm water or milk and water 
should be allowed to play gently upon them, until all the discharge 
is washed away. Still better is it to employ for this purpose a 
small syringe, the nozzle of which is to be gently inserted between 
the eyelids. The syringe should be very carefully and delicately 
handled, otherwise it will bruise and irritate the eye, or even per- 



PURULENT OPHTHALMIA. 49 

haps rub against the cornea. The nurse must also be very careful 
that no drop of the returning fluid is thrown into ber eye. In 
severe cases the eye should be thus cleansed every hour or two, in 
milder cases three or four times daily will suffice. The bichloride 
of mercury lotion may also be used for cleansing the eye instead 
of warm water. The crusts which form upon the eyelashes should 
be well soaked with warm water and then gently removed, so as 
not to excoriate the lids. A little simple cerate should be applied 
to the edges of the latter, night and morning, to prevent their 
sticking, or if they are getting sore the citrine ointment may be 
substituted. If the temperature of the lids is but moderately in- 
creased, it is only necessary to employ cold compresses for an hour 
or two after the application of caustics, for we thus assist the 
astringent action of the caustic upon the bloodvessels, and also 
moderate the reaction produced by it. But if the attack is very 
severe, and the eyelids very red, swollen, and hot, a temporary use 
of cold water will not suffice, and we must have recourse to a con- 
stant application of ice compresses. They should be applied in the 
following manner: slightly moistened pledgets of lint, of a suffi- 
cient size to cover both eyelids, should be laid upon a lump of ice 
until they are quite cold, when they are to be applied to the eye- 
lids and changed as soon as they get the least warm. Several of 
sucb pledgets should be kept lying upon the ice, so that one is 
always ready for use. If the temperature of the lids is very high, 
the lint may require to be changed every three or four minutes.. 
It is, therefore, absolutely necessary to have a nurse for each 
patient, or at least for every two. Instead of the lint, the small 
caoutchouc ice bags may be employed. If great attention cannot 
be paid to the application of the ice compresses, it is better to- 
abstain altogether from their use, as they may otherwise do more 
harm than good. We must then rest satisfied with the cold water- 
dressing or Goulard lotion. When the eyelids become cooler and 
less red, the patient begins to find the extreme cold disagreeable,, 
and then cold water dressing should be substituted for the ice com- 
press, or it may even be necessary to pass over to the use of warm 
fomentations. A constant small stream of cold water may also be 
allowed . to play upon the eyelids by means of a small syphon con- 
nected with a little reservoir placed at the bed head. 

Local depletion is often of great benefit. If there is much ciliary 
neuralgia, accompanied by great swelling, heat, and redness of the 
eyelids, and if these symptoms do not readily yield to cold com- 
presses, leeches should be at once applied. The best place for their 
application is on the temple, about an inch from the outer canthus,. 
for if they are put close to the eyelids, they often produce great 
oedema of the lids which may even extend to the cheek. Their 
number should vary from four to eight, according to the require- 
ments of the case. They should be applied two at a time, so that 
the effect may be prolonged, and free after-bleeding is to be encou- 
raged by warm fomentations. 

If the eyelids are much swollen, very tense, and press greatly 
4 



50 DISEASES OF THE CONJUNCTIVA. 

upon the eyeball, and especially if the cornea is beginning to 
become affected, the outer commissure of the lids should be divided. 
This will not only mitigate the injurious pressure of the lids upon 
the eyeball and cornea, but it will also give rise to free bleeding 
from the vessels which are divided, and thus greatly relieve the 
circulation of the external portions of the eye. The incision is to 
be carried through the skin and fibres of the orbicularis, but not 
through the mucous membrane, otherwise an ectropion might be 
produced. 

"We have now to consider the most important part of the treat- 
ment, namely, the topical application of caustics and astringents. 
At the commencement of the disease, whilst the discharge is still 
but moderate in quantity, we must be careful not to employ too 
strong a caustic, more especially if the eyelids are hard and the 
conjunctiva and papillae not much swollen, for fear that there 
should be a tendency to diphtheritic conjunctivitis, which would 
be greatly aggravated by free cauterization. As soon as the dis- 
charge has become copious,' and the symptoms of true purulent 
ophthalmia are well pronounced, astringents must be employed 
more energetically. The choice of the astringent and the mode of 
its application will depend upon circumstances. If we have to 
treat the person as an out-door hospital patient, and shall perhaps 
only see him every second or third day, it will be necessary to give 
him a remedy which can be readily and efficiently applied by some 
attendant. Under these circumstances I have found the injection 
of zinc and alum, as employed at the Royal London Ophthalmic 
Hospital, Moorfields, by far the best. Its strength, and the fre- 
quency of its application, must vary according to the severity of 
the disease. I generally employ a solution 2 grs. of sulphate of 
zinc and 4 or 6 grs. of alum to the ounce of distilled water. This 
is to be injected between the eyelids with a small glass syringe 
every 15 or 30 minutes during the day, and every two hours at 
night. As the condition of the eye improves, it is to be employed 
less frequently. Before its application, the discharge should be 
thoroughly washed away by an injection of lukewarm water, in order 
that the collyrium may come everywhere in contact with the sur- 
face of the conjunctiva. Every second or third day, the surgeon 
should apply a drop or two of a strong solution of nitrate of silver 
(gr. x to 3j of water) to the inside of the lids, or it should be brushed 
over the conjunctiva with a camel's hair brush ; the patient in the 
interval continuing with the injection. 

Much benefit may also be derived from a solution of nitrate of 
silver (gr. x to sj of water if the case is severe), which should be 
dropped into the eye every five or six hours, with a quill or camel's 
hair brush. But it is more difficult to apply these drops properly 
and efficiently than the injection, and it is therefore always better 
that the surgeon should, if possible, do this himself. My friend, 
Mr. Moss, has very successfully treated, at the Moorfields Hospital, 
out-patients suffering from very severe purulent or gonorrhceal 
ophthalmia, in the following manner, which was, I believe, sug- 



PURULENT OPHTHALMIA. 51 

gested to him by Professor Donders: The lids being well everted, 
he applies with a camel's hair brush a very strong solution of 
nitrate of silver (gr. xxx — to xl to the §j) to the conjunctiva once 
a day. In the intervals, the patient uses an injection of alum 
every half hour or hour. Quinine or steel is, at the same time, 
given internally. 

But if the patient is in the hospital, or can be frequently seen 
by the surgeon, I greatly prefer to apply the nitrate of silver in 
substance. It has this great advantage, that we can regulate and 
limit its effect, and prevent its coming in contact with the cornea 
and the ocular conjunctiva, which is quite impossible with the 
solution. Moreover, the latter is easily decomposed if the dis- 
charge is copious, and its effect is thus impaired. It is, however, 
absolutely necessary that the surgeon or a skilful assistant should 
apply it, as it cannot be entrusted to a nurse. We are indebted to 
Von Graefe 1 for the scientific explanation of the action of the 
nitrate of silver in purulent ophthalmia, and for very exact and 
comprehensive directions as to its use. During a prolonged stay 
in Berlin, I saw it employed most successfully in this way by Von 
Graefe in many cases of purulent ophthalmia. 

Pure nitrate of silver is too strong to apply in substance to the 
conjunctiva, as its escharotic action is too severe. It produces a 
thick eschar which is thrown off with difficulty, hence the super- 
ficial portion of the conjunctiva is very liable to become destroyed, 
and deep cicatrices may be produced. Its strength should, there- 
fore, be diluted by mixing it with one-half or two-thirds of nitrate 
of potash. 

The application is to be made in the following manner : The 
eyelids having been thoroughly everted, so as to bring the retro- 
tarsal fold well into view, the folds of the conjunctiva of the upper 
and lower lid should be allowed to cover the cornea, and thus pro- 
tect it from the action of the caustic. The crayon of mitigated 
nitrate of silver should then be lightly passed over every part of 
the surface of the palpebral conjunctiva, especially in the retro- 
tarsal region. A solution of salt and water should then be freely 
applied with a large camel's hair brush, in order to neutralize the 
nitrate of silver. The caseous shreds of chloride of silver, which 
are thus formed, should be washed away with clean cold water, 
before the lids are replaced. We can very easily regulate the 
action of the caustic. When but a slight effect is required, the 
crayon should be passed but once or twice very lightly over the 
conjunctiva. If a stronger action is desired, it may be used with 
more freedom. The neutralization with the salt and water should 
not take place immediately after the application of the caustic, 
except where the effect of the latter is to be but very slight. It 
should not, however, be postponed longer than from ten to fifteen 
seconds. 

The caustic should not, as a rule, be applied to the ocular con- 

' Von Graefe on Diphtheritic Conjunctivitis (" A. f. O.," vol. I.). 



52 DISEASES OF THE COXJUNOTI VA . 

junctiva, for, as this is but secondarily affected, its swelling and 
inflammation will generally subside as the condition of the palpe- 
bral conjunctiva improves. It may, however, be necessary to do 
so, if the chemosis is so considerable as to protrude between the 
lids, and does not yield to free incisions. But it should only be 
touched here and there, and the salt and water should be immedi- 
ately applied. 

If the swelling of the conjunctiva is very considerable, it should 
be freely scarified with a scalpel or Desmarres' scarifier, directly 
after the neutralization of the caustic ; and the bleeding should be 
encouraged by the application of hot sponges, and by slightly 
kneading the lids between the fingers. The incisions in the 
papillae should be very superficial, otherwise deep cicatrices will be 
left. The lids should on no account be scarified before the appli- 
cation of the nitrate of silver, for the latter would act too severely 
upon the incised conjunctiva. If the chemosis is great, incisions 
radiating towards the cornea should be made in it, either with a 
pair of scissors or a scalpel: or a small fold of conjunctiva may be 
snipped out with scissors near the outer edge of the cornea. Ice 
compresses are to be applied directly after the cauterization, for 
they diminish the inflammatory reaction, and assist in the contrac- 
tion of the bloodvessels. 

If we watch the condition of the eye, we shall find that it becomes 
very hot and painful directly after the cauterization, and that this 
is accompanied by increased lachrymation and a mucous discharge. 
The eschars which are formed upon the palpebral conjunctiva are 
shed in from 30—60 minutes in the form of little yellowish-white, 
rolled-up flakes. Those on the ocular conjunctiva remain some- 
what longer. The inflammatory symptoms soon subside, the con- 
junctiva becomes less turgid, the lachrymation and purulent dis- 
charge diminish, and the stage of remission sets in, during which 
the epithelium is regenerated. When this has taken place, the 
original condition, as it existed before the application of the caus- 
tic, begins to reappear. The conjunctiva becomes more red and 
swollen, the discharge increases in quantity, and the inflammatory 
symptoms in severity. It is of consequence to endeavor, by renewed 
cauterization, to cut short this third period at the outset, before it 
has regained its original intensity. "We shall thus be able, by de- 
grees, to extend the duration of the stage of remission, and to di- 
minish the intensity of the inflammatory stage. Generally, it will 
suffice to apply the crayon once in 24 hours ; in very severe cases it 
may be necessary to do so more frequently, but it should never be 
applied until the purulent discharge has again set in. 

Von Graefe has shown that the effect of the nitrate of silver (al- 
though it momentarily increases the congestion), is to contract the 
bloodvessels, and to accelerate the circulation, which is retarded in 
purulent ophthalmia, the conjunctiva being at the same time very 
vascular and congested, and its vessels dilated ; moreover, the serous 
infiltration of the conjunctiva is greatly relieved by the copious 
serous effusion which follows the cauterization. This is the period 



PURULENT OPHTHALMIA. 53 

of remission, during which the epithelial layer of the conjunctiva is 
regenerated. 

If the cornea becomes cloudy, a solution of atropine (gr. ij to 3j 
of distilled water) is to be dropped into the eye three or four times 
daily. Where the crayon is employed, the atropine should not be 
used until the period of remission has set in. If the nitrate of 
silver drops are used, the atropine should be applied during the in- 
tervals, and about two hours after the former. 

If there is a deep ulcer of the cornea, which threatens to perforate 
the latter, we should at once perform paracentesis by pricking the 
bottom of the ulcer, and letting the aqueous humor flow off very 
gently. The opening in the cornea will thus be extremely small ; 
a little portion of iris will fall against it, lymph will be effused, and 
the intraocular pressure being now taken off, the ulcer will begin to 
heal at the bottom. The re-accumulation of the aqueous humor 
will generally suffice to detach the portion of iris from the cornea. 
If, however, a small anterior synechia should persist, atropine drops 
should be applied, in order, if possible, to tear it through. It may 
be necessary to repeat the paracentesis several times, if we see that 
the bottom of the ulcer is being bulged forwards by the aqueous 
humor. By such a timely paracentesis we often limit the ulcer to 
a small extent, and finally little or no opacity of the cornea may 
remain. But if we permit the ulcer to perforate of its own accord, 
the opening will be much larger, for the bottom of the ulcer becomes 
attenuated and extended in size before the cornea gives way. The 
aqueous humor will then escape with considerable force, and carry 
the iris, or even, perhaps, the lens, if the perforation be large, 
into the opening in the cornea, and thus a considerable anterior 
synechia or prolapse of the iris, may occur. If the latter is consider- 
able it should be pricked with a fine needle, and the aqueous humor 
distending it be allowed to flow off, which will cause the prolapse 
to collapse. This may be repeated several times, until it shrinks 
and dwindles away. If this does not occur, the prolapse should be 
snipped off with a pair of scissors, after having been pricked. 
Should the lens have fallen into the opening and be presenting 
through, it should be at once removed, together, perhaps, with a 
little of the vitreous humor. An incision should be made through 
the central portion of the perforated cornea, with Von Graefe's 
narrow cataract knife. If a piece of iris protrudes, this should be 
somewhat drawn out and snipped off The capsule should be freely 
lacerated with the pricker, and the lens will then readily escape if 
a little pressure is made upon the eye. A little vitreous humor will 
generally exude, and the lips of the incision fall into close apposi- 
tion. A firm compress bandage should be carefully applied, so as 
to keep the eye immovable and the vitreous pressed back. Should 
the latter show a tendency to protrude through the incision, and 
thus interfere with its firm cicatrization, it should be pricked, and 
a little be allowed to escape, the bandage being then re-applied. 
We may thus be able to save a sufficient portion of clear cornea to 



54 



DISEASES OF THE CONJUNCTIVA. 



permit of the subsequent restoration of some useful degree of sight, 
by the formation of an artificial pupil. 

If the disease has become chronic, the nitrate of silver must be 
less frequently applied, or it should be exchanged for, or alternated 
with, the use of sulphate of copper in substance. A crayon of this 
should be passed lightly over the palpebral conjunctiva, more par- 
ticularly in the retro-tarsal region, once every day. Or, a solution of 
sulphate of copper (gr. ij ad oj) should be dropped into the eye once 
or twice daily. The astringent must be occasionally changed, as 
the conjunctiva after a time becomes accustomed to it, and it loses 
its effect. Thus, we may alternate the sulphate of copper with a 
collyrium of the sulphate, acetate, or chloride of zinc, alum, acetate 
of lead, or vinum opii, or the red or white precipitate ointment may 
be applied to the conjunctiva. If the papillae are much swollen and 
very prominent, like cauliflower excrescences, it may be necessary 
to snip them off with a pair of scissors. 



4 — GONORRHEAL OPHTHALMIA. 

Gonnorrhceal ophthalmia is one of the most dangerous and viru- 
lent diseases of the eye. In the majority of cases it presents the 
symptoms of a very severe purulent ophthalmia, accompanied some- 
times by marked constitutional disturbance. 

Shortly after the infection, the patient experiences a feeling of 




After Dalrymple.] 



tingling and smarting in the eye, as if a little grit or sand had 
become lodged beneath the lids. The eye becomes red, watery, and 
irritable, and the edges of the eyelids somewhat glued together by 



GONORRHEAL OPHTHALMIA. 55 

a slight grayish-white discharge. These symptoms rapidly increase 
in severity, and the disease quickly assumes the character of puru- 
lent ophthalmia of an aggravated type. The eyelids become 
greatly swollen, hot, red, and oedematous [Fig. 16], the conjunctiva 
very vascular, swollen, and villous ; the chemosis is often also very 
considerable [Fig. 17], enveloping and overlapping the cornea, and 
protruding between the lids. The discharge is thick and creamy, 
and perhaps so profuse that it oozes out between the lids, and when 
they are opened streams over the cheek. There is always great 
danger of the cornea becoming affected with deep and extensive 
ulceration,, which frequently quickly leads to perforation. The 
constitutional symptoms are often severe ; the patients being gene- 
rally in a feeble and weakly condition, their general health having 
perhaps suffered from the existence of the gonorrhoea. 

Sometimes, the disease shows from the outset a marked tendency 
to assume the character of diphtheritic conjunctivitis, and this 
proves especially dangerous- to the eye. In such cases, we notice 
that the conjunctiva, instead of presenting the usual red, vascular, 
succulent appearance common to purulent ophthalmia, becomes 
pale, smooth, and infiltrated with a fibrinous exudation. The dis- 
charge is also quite different, being thin, gray, and watery. The 
cases of gonorrhoeal ophthalmia which prove so virulent as to 
destroy the cornea in the course of a few hours are probably mostly 
of this diphtheritic, or, at all events, of a mixed character. In 
England, however, this form is very rare, and amongst the nume- 
rous cases of gonorrhoeal ophthalmia which have come under my 
care or observation, I have only met with the purulent disease. 

Gonorrhoeal ophthalmia is always due to contagion, and the 
doctrine of metastasis (which was formerly much in vogue) is 
quite untenable. It may be produced during any stage of the 
urethral disease, but about the third week of the existence of the 
latter is the most dangerous period, the discharge being then very 
copious, thick, and noxious. I have, however, seen the discharge 
from a gleet give rise to severe and even destructive gonorrhoeal 
ophthalmia. Medical men unfortunately sometimes altogether 
neglect to warn their patients of the danger of contagion from the 
urethral discharge. I have met with several instances of severe 
and destructive gonorrhoeal ophthalmia, in which the patients had 
never been informed by their medical men of the very contagious 
character of the discharge from the urethra, and had accidentally 
inoculated one of their eyes. 

Gonorrhoeal ophthalmia is far more frequent amongst men than 
women, and the right eye is the one usually attacked, the corre- 
sponding hand being most used for the purpose of ablution, etc., 
and, consequently, most prone to be the carrier of the virus to the 
eye. 

If we see the patient very shortly after the inoculation, the eye 
should be thoroughly syringed out with lukewarm water, and a 
drop or two of a weak solution of nitrate of silver (gr. ij ad sj) be 
at once applied, and repeated at the intervals of a few hours. Ice 



56 



DISEASES OF THE CONJUNCTIVA. 



compresses may also be employed. The other eye should be at once 
protected by the bermetical bandage (vide p. 48) against the danger 
of contagion. The treatment must be the same as that for puru- 
lent ophthalmia, the patient's health being sustained by tonics 
and a generous diet. But if the disease shows a tendency to 
assume the diphtheritic character, the use of astringents (more 
especially the nitrate of silver) must be particularly avoided, and 
the case must be treated upon the same principles as diphtheritic 
conjunctivitis, viz., by ice compresses, leeches, and, perhaps, the 
use of mercurials. 



5— OPHTHALMIA NEONATORUM. 



Strictly speaking, we cannot recognize this as a special form, for 
it assumes the character either of purulent or catarrhal ophthal- 
mia. It demands, however, some special remarks as to the treat- 
ment to be pursued. The inflammation, generally, appears first in 
one eve, the other becoming affected a few days later if preventive 
measures are not at once taken. The symptoms of the disease vary 
from those of mild catarrhal conjunctivitis to those of severe puru- 
lent ophthalmia. On account of the laxity of the tissues, there is 
great serous infiltration and swelling of the eyelids, even perhaps 
in the milder cases. [Fig. 18.] The papillae of the conjunctiva also 
become very prominent and swollen ; and there is often a great 
tendency to ectropion. 




After Dalrymple.] 



It has been stated by some authorities that the cornea is more 
frequently implicated in infants than in adults, but this does not 
appear to be the case, although suppuration of the cornea is of but 
too frequent occurrence, from the feeble and weakly condition of 
many of the infants, and the negligence and want of care in the 
nursing, which is so often met with amongst the out-patients of 
an hospital. 



OPHTHALMIA NEONATORUM. 57 

Contagion is a very frequent cause of the disease. The infection 
often occurs from some leucorrhoeal, or perhaps gonorrhoeal dis- 
charge during the passage of the child through the vagina. But 
it must be always remembered that other vaginal discharges be- 
sides the gonorrhoeal may induce this ophthalmia. The disease 
may also be produced by the child's eyes being wiped and cleansed 
with a sponge or cloth which is soiled with some vaginal discharge. 
Frequently, the ophthalmia is not due to contagion at all, but is 
caused by the sudden exposure of the infant to the irritation of 
bright dazzling light, cold winds, or by a want of cleanliness in 
washing the eyes. This is proved by the fact that the disease 
sometimes does not make its appearance till some weeks after 
birth ; whereas if it were due to contagion this would not be the 
case, for we find in inoculation that the period of incubation lasts 
from 12 to 70 hours. 

The course of ophthalmia neonatorum is generally much less 
intense than that of purulent ophthalmia (due to contagion) in 
adults. 

Although the pure diphtheritic conjunctivitis never occurs in 
new-horn infants, yet we sometimes meet with mixed forms, in 
which during the early stages, the purulent ophthalmia shows a 
more or less marked tendency to assume a somewhat diphtheritic 
appearance. The lids are not soft and flaccid (doughy) but stiff, 
and rather hard, and their temperature is high. The surface of 
the conjunctiva is of a pale or yellowish gray tint, the papillae 
being not much swollen ; the discharge, instead of being thick and 
creamy, is thin, fibrinous, and rather flaky, so that it adheres 
somewhat to the conjunctiva, and has to be removed with forceps, 
exposing beneath it a red succulent surface. These peculiar symp- 
toms are simply due to a stasis in the bloodvessels, and the fibrinous 
mass does not penetrate into the substance of the conjunctiva, as 
is the case in the diphtheritic form. 

The prognosis will depend upon the severity of the attack, and 
the condition of the cornea, the same rules holding good as in 
purulent ophthalmia (p. 47) ; and if there . be any epidemic, upon 
the nature of this in general. 

Treatment. — The first indication is prevention. The eyes should 
be washed with warm water directly after birth, and this should 
be repeated frequently. The sponges, towels, lint, etc., should be 
perfectly clean, and used for no other purpose. The hands of the 
nurse and the mother (more especially if she is suft'ering from any 
vaginal discharge) should always be washed before the infant's 
eyes are cleansed. If the disease breaks out in a workhouse, or 
lying-in charity, the children suffering from it should be separated 
from the healthy, and should have special nurses. Moreover, they 
should not be crowded together into small ill-ventilated wards, but 
enjoy plenty of fresh air. 

If the eyes look red and irritable, with a discharge at the corners 
or upon the lashes, a weak collyrium of sulphate of zinc (gr. j — ij 
ad gj) should be used 2—3 times daily, and the eyes frequently 



58 DISEASES OF THE CONJUNCTIVA. 

cleansed. But if the discharge is thick, creamy, and- considerable 
in quantity, stronger astringents must be employed. In out-patient 
practice, where the patients can only be seen two or three times a 
week, by far the best remedy is the injection of the eollyrium of 
alum and zinc (Zinc, sulph. gr. ij, Alum. gr. iv, Aq. dest. Ij). A 
little of this is to be injected with a glass syringe between the lids 
every quarter or half hour during the day, and every three or four 
hours during the night. The frequency of the injection must be 
regulated according to the severity of the disease. The eyes are 
to be cleansed before the use of the eollyrium by the injection of 
lukewarm water between the lids, so that the discharge may be 
washed away. If the patient can be seen every day, or even more 
frequently, the mitigated nitrate of silver, in substance, should be 
used, as we can regulate and localize its effect far better than can 
be done if injections or collyria are employed. During the early 
stage of the ophthalmia, the nitrate of silver, either in substance 
or strong solution, should always be employed with great care and 
circumspection, even although there may be a considerable degree 
of swelling and succulence of the conjunctiva. For the reaction is 
apt to be too great and prolonged, the eschars being only very 
tardily thrown off ; and this great reaction may give rise to small 
marginal infiltrations of the cornea, which, if due precautions be 
not taken, may easily pass over into ulcers. 1 Hence it is always 
wiser, at the outset of the disease, never to use a stronger solution 
of nitrate of silver than 2 — 5 grains to the ounce. The edges of 
the lids should be smeared night and morning with simple cerate, 
or, if they are sore and excoriated, with a little citrine ointment. 
For severe cases, other local remedies are also indicated, e.g., leeches, 
scarification, cold compresses, etc. But we unfortunately encounter 
great difficulty in their proper employment, except in a special 
hospital, or in private practice. The nurses or parents are often so 
careless in the application of cold compresses that they do more 
harm than good. 

If there is a tendency to stasis in the circulation of the con- 
junctiva, and to the formation of the above-named fibrinous mem- 
branes, the astringents must be used with care, and their effect 
closely watched. If mitigated nitrate of silver in substance is 
employed, it should be only lightly used, at once neutralized by 
salt and water, and the cauterization be followed by free scarifica- 
tion and the application of cold compresses to the eyelids. Wecker, 
moreover, recommends the administration of small doses of calomel 
during this condition of cyanosis of the conjunctiva. Affections 
of the cornea must be treated in the same way as in purulent 
ophthalmia. The health of the mother or wet-nurse should also 
be attended to. If the infant is feeble, and the ophthalmia shows 
a tendency to become chronic, and the mother is out of health, 
tonics and a generous diet should be prescribed. 

1 Vide Dr. Alfred Graefe's paper, "Kl. Monatsbl.," 1865, p. 374. 



DIPHTHERITIC CONJUNCTIVITIS. 59 



6.— DIPHTHERITIC CONJUNCTIVITIS. 

This extremely dangerous disease is fortunately very rare in 
England. I have never yet met with a case of pure diphtheritic 
conjunctivitis here, whereas during my residence in Berlin, I had 
the opportunity of seeing many cases in Von G-raefe's clinique. 
Indeed, it is of frequent occurrence in that city, and often assumes 
a very severe and even epidemic character. 

The first symptom is very rapid and great swelling of the eye- 
lids, which are also hard and firm, very hot, and exquisitely tender, 
so that the patient shrinks back and trembles at the mere idea of 
their being touched. The swelling and stiffness of the eyelids soon 
become so great, that they can hardly be opened, and certainly 
not everted ; whereas in purulent ophthalmia we have seen that 
although the eyelids may be greatly swollen, they are soft, flaccid, 
and not painful to the touch, nor is the temperature very high ; 
they can also be readily everted. 

The conjunctiva is at first somewhat red, but soon assumes a 
grayish-yellow tint, especially at the retro-tarsal fold. It is not 
soft, red, succulent, and villous, as in purulent ophthalmia, but 
thick, smooth, and somewhat glistening. This pale, grayish-yel- 
low tint is chiefly due to the firm, gelatino-fibrinous infiltration of 
the substance of the conjunctiva, which compresses the bloodvessels, 
and gives rise to a great retardation, or even stoppage in the cir- 
culation. Numerous extravasations of blood may also be noticed 
on the conjunctiva. The ehemosis is pale and yellow, but the in- 
filtration is not serous and transparent, but firm and fibrinous, 
pressing upon and strangulating the bloodvessels which supply the 
cornea, and hence the great danger which the latter runs in this 
disease. When the lids are opened, a stream of hot, scalding tears 
gushes forth, mixed perhaps with a few yellow fibrinous flakes, 
quite different to the thick creamy discharge in purulent ophthal- 
mia. 

Even deep scarification of the conjunctiva fails to produce a 
copious sanguineous discharge, for the latter is either thin, scanty, 
and of a reddish-yellow tint, or the incisions remain almost dry. 

The discharge on the surface of the conjunctiva often assumes 
the form of thin, yellowish, reticulated patches, of varying size. In 
some cases, thick opaque membranes are formed, which are so co- 
herent that they can be stripped off in large pieces, forming casts 
of the lids and the surface of the eyeball. Their forcible removal 
may cause considerable bleeding, but we do not find, as is the case 
in purulent ophthalmia, that the denuded conjunctiva presents a 
red, succulent, villous surface, but we come down upon another 
layer of yellowish-gray fibrinous infiltration. In fact, the latter 
is not confined to the surface of the conjunctiva, but extends more 
or less deeply into its stroma. 

The disease is not always accompanied by such severe inflamma- 
tory symptoms, but may run a milder and less dangerous course. 



60 DISEASES OF THE CONJUNCT! VA . 

It may occur as a" primary affection, or ensue secondarily upon 
purulent ophthalmia, the latter assuming a diphtheritic character. 

In the primary form, it generally sets in with considerable vio- 
lence, all the characteristic symptoms showing themselves in two 
or three days ; indeed, the disease may even attain its acme in 
that time, remain stationary for a few days, and then gradually 
pass over into the second or blenorrhoic stage. The latter is 
ushered in by the following symptoms: The lids diminish in 
hardness and become more soft and flaccid, so that they can be 
everted with greater ease, and without much pain. The surface 
oLthe conjunctiva assumes a more vascular and succulent appear- 
ance ; here and there patches of fibrinous exudation soften and 
become detached from the surface of the conjunctiva, which bleeds 
more or less freely. The deep-seated infiltration gradually di- 
minishes, and this is accompanied by a corresponding diminution 
in the firmness and hardness of the conjunctiva, which assumes a 
more vascular, succulent, and villous appearance, the discharge at 
the same time becoming thick, creamy, and copious. In fact, the 
disease now presents the characters of purulent ophthalmia, with 
this peculiarity, however, that there is a great tendency to the for- 
mation of cicatrices, and shrinking of the conjunctiva. But some- 
times there is a relapse after the purulent stage has set in, the 
diphtheritic symptoms reappearing with more or less prominence, 
and such relapses may occur more than once. This is especially 
the case if the use of astringents has been commenced too early, or 
they have been too energetically employed. 

Diphtheritic conjunctivitis is a far more dangerous disease than 
purulent ophthalmia, on account of the frequency and severity of 
corneal complications. Extensive ulceration or suppuration of the 
cornea is but too frequent. The dense, hard, infiltrated conjunctiva 
presses upon the cornea and upon the bloodvessels which supply it, 
hence the nutrition of the cornea is greatly impaired, and its sup- 
puration may rapidly ensue. If the cornea is about to be impli- 
cated, we notice that its lustre is slightly diminished, its surface 
faintly clouded, and its epithelial layer somewhat abraded. A 
yellow infiltration appears, which rapidly passes over into an ulcer, 
the latter extending quickly in circumference and depth, until a 
very considerable portion of the cornea may be involved. In some 
cases, when the ulcer has extended nearly as far as the membrane 
of Descemet, its floor becomes somewhat more transparent, and 
bulged forward by the aqueous humor. The patient's sight is 
temporarily much improved, and he is buoyed up by the vain hope 
that his eye is safe ; but, perforation generally rapidly ensues. If 
the disease is very severe, and the cornea has become affected at a 
very early stage, the whole cornea may suppurate, give way, and a 
considerable amount of the contents of the globe escape. The 
perforation is soon blocked up by a glutinous exudation, which 
also glues down the edges of the prolapsed portion of iris to the 
cornea. The earlier the cornea becomes affected, the greater is the 
danger, for the ulcers which occur at a later period of the disease 



DIPHTHERITIC CONJUNCTIVITIS. 61 

spread less rapidly, and show a greater tendency to limitation. 
We also find, as in purulent ophthalmia, that those eyes are safest 
in which there exist either vascular ulcers of the cornea, or a vas- 
cular pannus, for then the nutrition of the cornea is carried on by 
the bloodvessels upon its surface, and there is far less danger of its 
undergoing suppuration. 

The prognosis is very unfavorable if the disease is at all intense, 
and the character of the epidemic (if such exist) is severe, and if the 
patient is an adult. It is somewhat more favorable in children, and 
towards the end of the epidemic; also if the first stage of the dis- 
ease is not very severe. 

In framing our prognosis, we must be chiefly guided by the 
severity of the inflammatory symptoms, the amount of the fibrin- 
ous exudation, the swelling and hardness of the lids and of the 
chemosis, and especially by the condition of the cornea. If the 
latter becomes affected very shortly after (within 24 — 36 hours) 
the outbreak of the disease, or during the first period, before that 
of vascularization has set in, we must look upon the eye as all but 
lost. If the cornea is not implicated until the second period (that 
of purulent ophthalmia) has set in, the prognosis is more favorable, 
but even in this case we must remember that a relapse may occur, 
and the safety of the eye be again endangered. 

The causes of diphtheritic conjunctivitis are very much the same 
as those which may produce other inflammations of the conjunc- 
tiva ; but it must be conceded that there is generally some consti- 
tutional peculiarity which determines the character of the disease, 
the same causes — exposure to cold, draughts, inoculation, etc. — 
producing in one case a purulent or granular, in the other a diph- 
theritic ophthalmia, moreover, it generally affects both eyes, how- 
ever much we may guard the second. It occurs most frequently in 
weakly and scrofulous persons, more especially in children between 
the ages of two and eight, of a delicate, feeble habit, or affected 
with hereditary syphilis. In them it often occurs in conjunction 
with croup or diphtheria. Contagion is also a very frequent cause, 
for the discharge from diphtheritic conjunctivitis is exceedingly 
contagious. If it be applied to a healthy conjunctiva it generally 
reproduces diphtheritic conjunctivitis, but this does not necessarily 
follow. The infection may be carried by the atmosphere, and not 
be due to direct contagion from sponges, towels, etc. 1 Sometimes 
the disease occurs epidemically, which is especially the case in some 
parts of Germany, more particularly in Berlin. 

The injudicious and excessive use of caustics in the treatment of 
purulent ophthalmia (more particularly that of children) may change 
the disease into the diphtheritic form. 

With regard to the treatment, it must be confessed that we have, 
unfortunately, but little control over the disease during the first 
period. 

Our first care must be to remove the patient from all noxious 

i Vide Dr. Homer's article, "Kl. Monat&bl.," 1860, May, p. 137. 



62 DISEASES OF THE CONJUNCTIVA. 

influences that may keep up and intensify the disease, and every 
effort must be made to prevent its spreading. 

We must endeavor to diminish the inflammatory symptoms, more 
particularly if they assume a sthenic type. If the eyelids are greatly 
swollen, and very red, hot, stiff, and painful, ice compresses must 
he employed almost without intermission, being changed as soon as 
they become at all warm. They must be less frequently employed 
when the second period (that of vascularization) is setting in, and 
when this has become fully established, they must be only used 
after the cauterization. The effect of the cold is to counteract the 
stasis by causing contraction of the vessels, and it also acts as a 
sedative, giving great relief to the intense pain. But if there is 
extensive ulceration of the cornea, the cold compresses should be 
replaced by warm fomentations, so that we may produce an accele- 
ration in the vascularity of the conjunctiva. Indeed, lately some 
surgeons, especially Berlin 1 and Mooren 2 have recommended the 
substitution of warm fomentations for the ice compresses, on the 
ground that they bring about the second period more rapidly. Thus 
they may prove of advantage when ulceration of the cornea occurs 
during the first period, and the ulcer shows no tendency to become 
limited or vascularized, for the tendency to necrosis is markedly 
aggravated by the application of cold or of caustics. Mooren for- 
merly always employed ice compresses, but in later years he has 
substituted the use of warm poultices, together with derivatives 
internally. But then he himself admits, that the disease never 
appears in Diisseldorf with the extreme intensity which it so often 
assumes in Berlin. 

If the cornea becomes implicated, atropine must be at once em- 
ployed in conjunction with the other local remedies, and the cor- 
neal affection treated in the manner mentioned at p. 53. 

Local depletion also proves of much service. Unfortunately, the 
disease occurs so frequently in ansemic and cachectic individuals, 
that we generally cannot make a full use of this. In adults, more 
particularly if the disease is due to contagion, and the patient robust 
and strong, leeches should be applied in large quantities to the tem- 
ples, or at the upper angle of the nose. Three or four leeches should 
be applied at a time, and as soon as these drop off they are to be 
replaced by others. But care must be taken not to push this 
remedy too far, especially in feeble persons, for by greatly weaken- 
ing the patient we increase the danger of sloughing of the cornea. 
In very severe cases as many as 30—40 leeches (Wecker) or even a 
greater quantity (Graefe) may have to be applied before any im- 
pression is made upon the disease. 

Scarification is but of little, if any, use during the first stage, for 
only a very small quantity of blood is obtained ; indeed, sometimes 
it may even do positive harm, being followed by a more consider- 
able fibrinous infiltration; but when the second stage has set in, 



1 " Kl. Monatsbl.," 1864, p. 259. 
" Oplithalmiatrische Beobachtungen," p. 70. 



2 !' 



GRANULAR OPHTHALMIA. 



63 



when the conjunctiva has become more vascular and there is an 
eft'usion of serum into it, scarification is often of much benefit. 
The incision should be somewhat deeper than in purulent ophthal- 
mia, and the bleeding be kept up by kneading the lids. 

In order to hasten the vascularization and the breaking down 
and elimination of the fibrinous infiltration of the conjunctiva, the 
system should be got as quickly as possible under the influence of 
mercury, so that salivation may be produced in the course of 30 — 
40 hours. The mercury may either be administered internally in 
the form of calomel and opium (calomel gr. ss — gr. j every 2 — 3 
hours) in doses varying with the age of the patient, or from 3ss — 
3j of the mercurial ointment should be rubbed in three times daily. 
In very severe cases, the rapidity with which the fibrinous infiltra- 
tion pervades the conjunctiva is often so great that the cornea 
becomes implicated and the eye lost, before the system can be 
brought under the influence of mercury. Moreover, the free use of 
this remedy is often contra-indicated by the very feeble and cachec- 
tic condition of the patient, in which case tonics, more especially 
quinine and preparations of iron, should be administered, and the 
patient be placed on a generous diet. ' 

When the disease is passing over into the second stage, and is 
assuming more and more the character of purulent ophthalmia, we 
must gradually commence the use of the mitigated nitrate of silver. 
But at first the cauterization must be employed with great care and 
discretion, as there is always the risk of causing a relapse if it be 
used with too great a freedom at once. Should symptoms of stasis 
reappear the cauterization must be immediately abandoned until 
these have passed away, and the disease again assumes the puru- 
lent character. 



7.— GRANULAR OPHTHALMIA. 

It has been already mentioned that in catarrhal and purulent oph- 
thalmia, the papillae of the conjunctiva are often much swollen and 
hypertrophied, forming more or less 
prominent elevations on the palpebral 
conjunctiva. [Fig. 19.] They appear 
in the form of bright or bluish-red, vel- 
vety, succulent elevations, which have 
no distinct pedicle, but seem to pass 
over into the tissue of the conjunc- 
tiva. They are ranged in rows, and 
are of course confined to that portion 
of the conjunctiva which contains 
papillae. Commencing at about a 
line from the free margin of the lid, 
they extend slightly beyond its tar- 
sal border ; their sides are generally 
flattened, on account of the papillae 
being pressed against each other. 




64 DISEASES OF THE CONJUNCTIVA. 

They are often very conspicuous at the angles of the eye, and 
assume also a considerable size near the retro-tarsal fold, look- 
ing perhaps like large warty excrescences. The name of granular 
lids is but too often given to this hypertrophied condition of the 
papillae, instead of being limited to the true granulations, which 
are neoplastic formations, and not swollen papillae. On account 
of this error, the greatest confusion still reigns upon this subject, 
a confusion which not only materially affects the diagnosis but 
also the treatment of the disease. What has tended still more to 
foster this misconception of the real nature of granular ophthalmia, 
is the fact that true granulations are generally accompanied in the 
course of their development, by a more or less swollen and hyper- 
trophied condition of the papilla?. If the latter gain a consider- 
able prominence, the granulations may even be hidden by them. 
Stellwag von Carion 1 applies the term of "papillary trachoma or 
granulations" to these hypertrophied papillae, and I see no objec- 
tion to retaining this name, if it be only remembered that these 
differ altogether in their nature and mode of development from the 
true granulations. 

Before proceeding to the consideration of granular ophthalmia, I 
must call special attention to a peculiar vesicular condition of the 
conjunctiva, which is frequently premonitory of that affection. It 
is a matter of surprise that this condition, which has been so care- 
fully and elaborately described by several eminent continental 
writers, more especially Stromeyer, Bendz, and Warlomout, should 
have apparently altogether escaped the attention of many English 
ophthalmic surgeons ; indeed, we are principally indebted to two 
distinguished English military surgeons 2 for giving this subject due 
prominence in our medical literature, and calling the attention of 
the profession, and more especially of army medical men, to a con 
dition of the eye which is very important to all who have the 
charge of large bodies of men,- e. g., soldiers, paupers, convicts, etc. 

This vesicular condition of the conjunctiva is distinguished by 
the following symptoms : On everting the lower eyelid, we notice 
upon it small, round, transparent bodies like little sago grains or 
herpetic vesicles, which are situated directly beneath the epithelium. 
They mostly make their appearance first on the lower eyelid, and 
may, indeed, remain confined to it, but they generally extend to 
the upper eyelid, and I have seen a few rare instances in which 
they encroached considerably upon the ocular conjunctiva. The 
vesicles are sometimes isolated, and but few in number, being 
sparsely scattered about the conjunctiva, especially near the outer 
angle of the eye. In other cases, they are studded thickly over the 
palpebral conjunctiva and retro-tarsal fold. They cannot be emptied 

1 " Pracktische Augenheilkunde," 3d edition, p. 404. 1867. 

2 I refer here to the excellent and very interesting articles on " Military Ophthal- 
mia," by Dr. Frank, late of the Army Medical Department, and by Dr. Marston. 
Both deserve the careful study of all surgeons. The first appeared in the "Army 
Medical Blue Book," of 1862 ; the second in Beale's." Archives of Medicine," No. 
xi., 1862. 



GRANULAR OPHTHALMIA. 65 

of their contents by pricking, and differ in this from the sudamina 
of herpes, and the serous elevation of the epithelium of the con- 
junctiva, which is occasionally met with in catarrhal ophthalmia; 
moreover, in the latter condition the vesicles are much larger. 
The vesicles consist of a stroma of connective tissue containing 
nucleated cells like lymph corpuscles, with a little fluid. They 
are surrounded by a delicate layer of condensed connective tissue, 
Avhich has no proper enveloping membrane, but passes over into 
the neighboring less condensed tissue. With a fine needle we may 
often succeed in removing them entire. They seem to be identical 
in structure with the closed follicles of the intestines, etc. Some- 
times these vesicles appear without any change in the conjunctiva. 
Generally, however, there is an increased vascularity of this mem- 
brane with some swelling, more especially at the retro-tarsal fold. 
The vessels of the conjunctiva are very apparent, and often of a 
dusky bluish-red color, sending small branches towards the vesicles, 
which may appear arranged in rows like little transparent beads. 
But this hypersemic condition may sometimes mask the presence 
of the vesicles, especially if they are small and not very numerous, 
so that they might readily be overlooked by a superficial observer. 
If the conjunctiva is however examined through a magnifying 
glass, they will be easily distinguished. 1 

If the hypenemia of the conjunctiva is but slight, these vesicles 
may exist for a very long time, for months or years, without pro- 
ducing any sensible discomfort or symptoms of inflammation. 
The patient may either be quite unaware that there is anything 
the matter with his eyes, or he may only notice a slight sensation 
of pricking or itching in the eye, the lashes being perhaps some- 
what glued together in the morning. There may also be a tendency 
to irritability of the eyes during reading or writing, more espe- 
cially by artificial light. Sometimes, however, even these symp- 
toms are entirely absent. 

This vesicular condition of the conjunctiva is due to an enlarge- 
ment of the closed lymphatic follicles of Krause, which are situated 
directly beneath the epithelium, and which are not apparent in a 
normal state of the conjunctiva, but become swollen and enlarged 
when this membrane is in an irritable condition. Stromeyer 2 called 
special attention to these vesicular granulations, but supposed that 
they were pathological products, and did not exist in a healthy 
conjunctiva. The researches of Krause and Dr. Schmidt of Berlin 
have, however, distinctly proved that they are physiological organs, 
which are not apparent to the naked eye whilst the conjunctiva is 

1 In a recent article on trachoma, in Graefe's Archiv. (xv. 1, 129), Dr. Blum- 
berg states that his researches have led him to consider the trachom granulations 

' as circumscribed hyperplasia of the lymphoid cells, which pre-exist in the normal 
conjunctiva, and are scattered about in its reticulated connective tissue. In the 
further progress of the disease, the trachom follicles undergo fatty and caseous 
(tubercular) degeneration, and finally cicatricial changes, which lead to a con- 
traction of the surrounding conjunctival tissue. In this last stage, such complica- 
tions as entropion trichiasis, pannus, etc., begin to manifest themselves. 

2 Stromeyer, "Maximen der Kriegshcilkunst." 1861. 

5 



66 DISEASES OF THE CONJUNCTIVA. 

in a normal condition, but are apt to become enlarged into these 
sago grain vesicles from a proliferation of their contents, more 
especially of their connective tissue elements, when there is any 
chronic irritation of the conjunctiva. 

JSTow it is a very important question, and one which has not at 
present received a decided and satisfactory answer, whether the 
true granulations are developed from these vesicular bodies, or 
rather the follicles of Krause, or whether they are a distinct neo- 
plastic formation, due to a proliferation of the contents of the con- 
nective tissue cells of the conjunctiva. The former view is main- 
tained by several observers of eminence, more especially Bendz 
and Stromeyer. But one weighty argument against this view is 
furnished by the fact that true granulations sometimes occur in 
situations where these follicles are more or less completely wanting, 
as for instance on the ocular conjunctiva. Wecker strongly advo- 
cates the view that the true granulations are neo-plastic formations, 
akin to tubercle, and are due to a proliferation of the contents of 
the connective tissue cells, and that they consist of a mass of 
closely packed nuclei with little or no connective tissue between, 
them. At a later stage, the connective tissue becomes increased 
in quantity, and forms a semi-transparent, gelatinous, grumous 
mass containing a small quantity of fat. The nuclei diminish in 
number, and are finally only sparsely scattered amongst the con- 
nective tissue. It is an important fact that this gelatinous mass 
becomes transformed at a later stage into a dense fibrillar tissue, 
and that the latter shows a great tendency to contraction, thus 
causing more or less destruction of the true conjunctival tissue. 
A firm cicatricial tissue is formed, which gives a streaky, tendi- 
nous appearance to the inner surface of the lids ; the latter gradually 
become shortened, the retro-tarsal fold almost obliterated, the tarsal 
cartilages incurved, thus giving rise to trichiasis and entropion. 

I have never had the opportunity of distinctly tracing the trans- 
formation of the vesicles into true granulations, as they are far less 
frequently met with in civil than in military practice. Moreover, 
we cannot watch the patients so constantly and closely. They 
attend perhaps for some length of time with vesicular granulations, 
and are then lost sight of. The same difficulty exists with regard 
to the determination as to whether a given case of acute or chronic 
granulations has been preceded by a vesicular condition of the lids, 
for it has been already stated that the latter may exist for a long 
time without the knowledge of the patient. The definite settle- 
ment of these questions will, I think, depend very much upon the 
observations made by our military confreres, who enjoy every oppor- 
tunity of constantly watching the development of the disease from 
its earliest (vesicular) stage to the latest, and their experience upon 
these points is, therefore, of the greatest importance. 
_ But whether we accept or not the theory that vesicular granula- 
tions are the first symptoms of granular ophthalmia, and may 
become developed into true granulations, there cannot be the 
slightest doubt that they must be regarded as a strongly predis- 



GRANULAR OPHTHALMIA. 67 

posing cause of the latter. It is, therefore, ot great importance 
that their existence should be detected as early as possible, more 
especially where a large number of persons are collected together, 
as in barracks, workhouses, and schools. For this vesicular state 
of the conjunctiva must be watched with care and anxiety, as it 
chiefly occurs in individuals living in a confined and vitiated 
atmosphere, and under faulty sanitary arrangements. Proper 
hygienic measures should, therefore, be at once adopted, and the 
patients, if necessary, submitted to treatment ; for if these vesicular 
granulations be allowed to exist unchecked, and such eyes are ex- 
posed to the usual irritating influences met with in marches and 
encampments, as for instance exposure to wind, dust, draughts of 
cold air, or bright glaring sunlight, an epidemic of granular oph- 
thalmia is but too likely to break out, the ravages and extent of 
which cannot be foretold. It is an interesting fact that Stromeyer 1 
also met with these vesicular granulations amongst many of the] 
domestic animals, more especially pigs, and that they existed in I 
proportion to the dirty condition in which these animals were kept. 
These observations, moreover, entirely agree with those made 
amongst human beings, for he found that vesicular granulations 
occur especially amongst persons inhabiting crowded, close, dirty, 
and ill-ventilated dwellings. 

Dr. Marston, who has enjoyed great opportunities of studying 
the phenomena of granular ophthalmia, holds similar views. He 
found 2 vesicular granulations very prevalent amongst the poorer 
classes in Gozo, especially where there was a large family, who 
live in wretchedly confined cabins, often with their domestic 
animals. With regard to the importance of vesicular granulations,, 
as being indicative of a vitiated state of the atmosphere, he says, 
" So certain do I feel that the prevalence of vesicular disease of" 
the lids is in direct ratio to the amount and degree of defective 
sanitary arrangements, that I conceive the palpebral conjunctiva 
offers a delicate test and evidence as to the hygienic conditions of 
a regiment." 3 

It is, therefore, of much importance to discover the presence of 
vesicular granulations as early as possible, in order that the hygienic- 
. conditions of the ward or sleeping apartment of the patient may 
be thoroughly examined. Such patieuts should be placed in large,, 
airy, well-ventilated rooms, which are not exposed to the bright 
sunlight. Strict orders should also be given that the same sponges,, 
towels, or water are not used for others. Indeed, it is advisable 
that even healthy persons should always wash in perfectly clean 
water which has not been already used by others. It is better to 
separate those affected with vesicular granulations from the healthy,, 

1 Stromeyer, "Maximen der Kriegsheilkunst," p. 49. 

8 Stromeyer, "Maximen cler Kriegsheilkunst," p. 201. 

3 To the military surgeon I would especially recommend the admirable article 
on "L'Ophthalmie Militaire en Belgique," by Drs. Warlomont and Testelin, in 
their French translation of Mackenzie. Also the valuable paper by Dr. Hairion,. 
published in the " Archives Beiges de Medecine Militaire, 1848." 



68 DISEASES OF THE CONJUNCTIVA. 

for I think that there can be. little doubt that vesicular granula- 
tions are contagious, more especially when they are accompanied 
by conjunctival swelling, and a little muco-purulent discharge. 
The patients should be in the open air as much as possible, care 
being taken, however, that they are not exposed to dust, wind, 
and bright sunlight. Their diet should be nutritious and easily 
digestible. If they are weak or scrofulous, quinine, steel, cod- 
liver oil, etc., should be administered. If there is slight conjunc- 
tivitis, with a little discharge, or small yellow shreds are formed 
on the conjunctiva, a weak astringent collyrium (Zinc, sulph. or 
Plumb, acetat., gr. 1 — i ad ,?j Aq. destill., or Boracis gr. iv — vj 
ad 3j) should be used, or the lids may be very lightly touched 
with a crayon of sulphate of copper, or still better, of the lapis 
divinus. Pricking the vesicles with a needle does little or no good. 
The eye douche or the pulverizer is found to be very beneficial and 
agreeable to the patient. I have occasionally met with this 
vesicular condition of the eyelids amongst wealthy persons, in 
whom the conjunctiva was in a state of irritation from exposure 
to cold, bright light, etc., and where no faulty hygienic arrange- 
ments could be discovered. The affection readily yielded to mild 
astringents, the eye douche, and careful guarding the eyes against 
exposure and too much reading, etc. Vesicular granulation may 
also be produced by the long-continued, use of atropine. I have 
lately met with some striking examples of this. The disuse of the 
atropine and the employment of a weak astringent collyrium, soon 
caused the granulations to disappear ; but, on the reapplication of 
atropine, a fresh crop rapidly sprung up. 

We must now pass on to the consideration of " Granular Ophthal- 
mia." In practice we , find that we may distinguish two special 
forms under which the disease shows itself, viz., the acute, which 
is often accompanied by severe inflammatory symptoms, and the 
chronic, in which these are sometimes but moderate, and occasion- 
ally almost entirely absent. Of course, we meet with numerous 
cases which cannot be properly placed in either category, but show 
a mixed character. Practically, it is, however, of much conse- 
quence to distinguish between the acute and chronic forms, for 
great and serious mischief may accrue from a mistaken diagnosis 
and treatment of a case of severe acute granular ophthalmia. 

ACUTE GRANULAR OPHTHALMIA. 

If the attack is severe, there are generally marked inflammatory 
symptoms ; the eyelids are red, swollen, and cedematpus, and on 
opening the eye, Ave see that there is a good deal of conjunctival 
and subconjunctival injection. The degree of conjunctival swell- 
ing varies; sometimes it is considerable, more especially in the 
retro-tarsal region, and there may also be marked serous chemosis. 
The photophobia and lachrymation are often very great, so that 
the patient is quite unable to open the eye, and directly it is 



ACUTE GEANOLAE OPHTHALMIA. 69 

attempted, hot scalding tears flow over the cheek. There is often 
severe throbbing pain in and around the eye, and perhaps over the 
corresponding half of the head. On eversion of the lids, we find 
that the conjunctiva is vascular and swollen, and that the papillse 
are prominent, red, and succulent. On closer inspection (with or 
without a magnifying glass) we notice, scattered between the 
papillse, and perhaps almost hidden by them, numerous small, 
round, white bodies, like sago grains, which are not, however, 
confined to the palpebral conjunctiva, but extend to the retro- 
tarsal fold. They are also sometimes seen on the ocular conjunc- 
tiva, and even on the cornea, where they give rise to a superficial 
vascular inflammation (pannus). If we examine the cornea in 
such a case by the oblique illumination, and through a magnifying 
glass, we fiud that this opacity is composed of a quantity of 
small elevated gray dots, with the epithelium raised over them. 
Numerous bloodvessels run over from the conjunctiva to these 
spots, giving a more or less red tint to the opacity of the cornea. 
This vascular opacity may involve a considerable portion of the 
cornea, and is not chiefly confined to the upper half, as is the case 
in the pannus produced by the friction of granulations or inverted 
eyelashes of the upper lid upon the surface of the cornea. Some- 
times small ulcers appear at the edge of the cornea. "When the 
acute stage has lasted for a few days, the symptoms of irritation 
begin to diminish. The severe pain, photophobia, and lachryma- 
tion decrease, the papillae at the same time becoming more turgid, 
vascular, and prominent, thus hiding the granulations ; whilst the 
discharge, which has hitherto been chiefly watery, with perhaps 
only a few yellow flakes suspended in it, becomes thicker and 
muco-purulent in character. The intensity of the conjunctival 
inflammation varies greatly ; sometimes it reaches only the catar- 
rhal form, at others it assumes a severe purulent type. The stage 
of purulent ophthalmia generally lasts for several weeks, and then 
the symptoms gradually subside ; the papillse diminish in size, and 
the white sago grain granulations are then perhaps found to have 
disappeared, they having in fact been absorbed during the inflam- 
matory state of the conjunctiva. But so favorable a result is not 
always obtained, for on the decrease of the inflammatory symp- 
toms, and the diminution in the size of the papillse, the white, and 
now more prominent, spots may reappear between them, the in- 
flammation having been insufficient for their absorption. If the 
patient is exposed to any fresh exciting cause, a relapse may occur, 
and a renewed attack of more or less severe acute ophthalmia may 
take place. This is, however, far less common than in the chronic 
form. 

Contagion is a very frequent cause, for the discharge from an 
eye affected with acute granulations is very contagious, more 
especially during the muco-purulent stage. It does not necessarily 
reproduce the same affection, but like purulent, or even diphtheritic 
ophthalmia, may give rise to catarrhal, purulent, or diphtheritic 
conjunctivitis. This will depend upon local and individual cir- 



70 DISEASES OP THE CONJUNCTIVA. 

cumstances, and upon the character of any epidemic of conjuncti- 
vitis that may be prevailing at the time. Another very fruitful 
source of acute granulations is defective hygiene ; the long-con- 
tinued use of atropine ma}' also produce them. 

The prognosis in acute granular ophthalmia is generally favorable, 
if the true nature of the affection is recognized at the outset, and 
a proper course of treatment is adopted. But if the disease is 
mistaken for a case of purulent ophthalmia, and freely treated by 
strong caustics, the intensity of the irritation will be greatly in- 
creased, and the inflammation may even assume a diphtheritic 
character. At the best, the salutary inflammation of the conjunc- 
tiva will be suppressed, and the absorption of the granulations 
checked. 

The treatment must vary with the nature and stage of the 
affection. We must especially remember that when the acute 
symptoms of irritation have subsided, our chief object is to obtain, 
if possible, the absorption of the granulations by keeping up a 
certain amount of inflammation of the conjunctiva. The degree 
of the latter should just suffice to promote this absorption, but 
should never be allowed to become so considerable as to arrest or 
retard it. 

If there is much photophobia, lachrymation, and ciliary irrita- 
tion, the greatest care must be taken to avoid all stimulating 
applications. Atropine drops (gr. ij ad 3j) should be applied 
three or four times daily. If they are, however, found to keep up 
or increase the irritability, they should be at once exchanged for a 
belladonna collyrium (Ext. bellad. Jss ad aq. destill. .?j), which 
should be applied somewhat more frequently, and in larger quan- 
tity. .At the same time, the compound belladonna ointment 
should be rubbed into the forehead every four or six hours, until 
a slight papular eruption is produced. If the pain in and around 
the eye is very severe, of a pulsating, throbbing character, and 
increases much towards night, a few leeches should be applied to 
the temple. Cold compresses are also of much benefit in subduing 
the irritation and relieving the pain. They must, however, be 
applied with circumspection, and their effect watched. If the cold 
is disagreeable to the patient, warm poppy or belladonna fomenta- 
tions should be substituted. If the conjunctiva is much swollen, 
more especially in the retro-tarsal region, it may be lightly scarified, 
care being taken to make the incisions very superficial, so that no 
cicatrices may be left. Much benefit and comfort are often ex- 
perienced from the application of a bandage, for this keeps the eye 
quiet, and prevents the irritation caused by the constant movements 
of the lids. 

When the symptoms of irritability subside, and the disease 
assumes the character of purulent ophthalmia, it must be treated 
on the same principles as that affection. The same rules as to the 
choice and mode of application of cautics apply as in the latter 
disease. The only difference being, that the cauterization must 
not be repeated so frequently, as we must remember that it is de- 



CHRONIC GRANULATIONS. 71 

sirable to maintain a certain degree of inflammation in order to 
favor- the absorption of the granulations. But care must be taken 
not to commence the use of caustics too early, whilst there is still 
considerable irritability of the eye, otherwise this will be greatly 
increased, and infiltrations, or even ulcers of the cornea, may be 
produced. In those cases in which we are in doubt as to whether 
the irritability of the eye is not still too great for the application 
of the nitrate of silver or sulphate of copper, it is always wiser to 
feel our way with some milder application. For this purpose we 
may try a weak solution (gr. vi — x ad |j) of the acetate of lead, a 
little of which should be painted over the granulations with a 
brush, and at once washed oft" with warm water, and if this is well 
borne, and causes a subsidence of the inflammatory symptoms, we 
may, in the course of a day or two, pass over to the use of the 
stronger caustics. But if any infiltrations or ulcers of the cornea 
exist, the acetate of lead should never be used, as it will be pre- 
cipitated upon the cornea, and give rise to very marked stains. 
Von Graefe 1 strongly recommends chlorine water for the purpose 
of paving the way for the use of stronger caustics in acute granu- 
lations. 

When the crayon of nitrate of silver and potash is applied, it 
should be at once neutralized by the application of salt and water. 
As a rule, the cauterization, should not be repeated more frequently 
than every 48 hours. Great care must be taken if any ulcers of 
the cornea exist, for they may be easily aggravated by too free a 
use of the nitrate of silver. If there is a great deal of irritation, I 
often apply atropine drops in the interval of the cauterization. 
When the swelling of the conjunctiva has considerably subsided, 
and the purulent discharge diminished, the sulphate of copper in 
substance, or a collyrium of acetate of lead, may be employed with 
advantage. If it is found that, together with the diminution of 
the inflammation and the size of the papillae, the granulations 
assume a more prominent character and increase in size and num- 
ber, this tendency to a neo-plastic formation must be checked at 
once, and their absorption hastened, by exciting a more con- 
siderable amount of inflammation by means of a freer use of some 
caustic, especially the sulphate of copper, which possesses the great 
advantage of increasing the inflammation without giving rise to 
thick firm eschars. 



CHRONIC GRANULATIONS. 

Instead of the very pronounced symptoms of irritation and in- 
flammation which are met with in acute granular ophthalmia, the 
inflammation accompanying the chronic form is often very slight, 
and may, indeed, be almost absent at the commencement of the 
affection. So that, in fact, persons may be suffering from chronic 

i "A. f. 0.,"x. 2, 197. 



72 DISEASES OF THE CONJUNCTIVA. 

granulations without being aware that there is anything particular 
the matter with their eyes ; the eyelids being only a little glued 
together in the morning, or there being perhaps a slight feeling of 
roughness under the eyelids. At the same time, the upper lid may 
hang down somewhat, its natural folds being more or less oblite- 
rated, and the palpebral aperture consequently narrowed. During 
all this time the conjunctival inflammation may be almost absent ; 
indeed, it is never very prominent, or in proportion to the amount 
of the granulations. On eversion of the lids, we at once notice the 
presence of the granulations in the form of small grayish-white 
bodies, like tapioca grains, more especially at the retro-tar3al fold, 
and in the vicinity of the angles of the eye. They may also appear 
on the palpebral conjunctiva, which is somewhat injected and 
swollen. In this situation, however, their size and number are 
less than at the retro-tarsal fold. These may be termed " simple 
granulations," or, according to Stellwag, "granular trachoma." 
Generally, however, this condition is soon followed by inflamma- 
tory symptoms. The conjunctiva becomes vascular, thickened, 
and swollen, and the papillae hypertrophied and prominent, having 
the granulations scattered between them. Here, therefore, we have 
true granulations existing side by side with the swollen papillae, 
and hence Stellwag calls this form "mixed granulations." The 
lids are more or less pulpy, the conjunctiva red and swollen, 
especially in the retro-tarsal region, and there is, perhaps, some 
chemosis round the cornea. The discharge, which was at first 
thin and watery, with only a few yellow flakes suspended in it, 
becomes thicker, more copious, and of a muco-purulent character. 
The eyes are very irritable, and the patient experiences a sensation 
as of grit or sand in them, especially under the upper lid, and is 
unable to expose them to wind, bright glare, dust, or to long-con- 
tinued work, without their becoming very red, watery, and in- 
flamed. 

But all these symptoms vary considerably in intensity, according 
to the degree of the accompanying conjunctival inflammation. 
Sometimes this assumes a mild catarrhal form ; in other cases it is 
more severe and of a purulent type. The course of the disease is 
often extremely protracted, extending over many months, or even 
years. A source of danger, as well as of annoyance and discomfort, 
is the tendency to relapses, the intensity of which also varies. 
Thus a mild attack of chronic mixed granulations may be nearly 
cured when from an exposure to some irritating cause, a relapse 
occurs, accompanied, perhaps, by a more severe form of conjuncti- 
vitis than the original one, and afresh crop of granulations appears 
before the former ones have been absorbed. These inflammatory 
symptoms are, however, rather due to a renewed swelling of the 
papillae than to a new formation of granulations. Sometimes these 
relapses are accompanied by considerable infiltrations of the cornea. 
Such relapses may occur again and again, leaving the eye each time 
in a worse condition, and gradually giving rise to various serious 
complications, such as pannus, trichiasis, entropion, etc. 



CHRONIC GRANULATIONS. 73 

If the attack is severe, and the crop of granulations very con- 
siderable, the infiltration but too often extends from the surface to 
the substance of the conjunctiva. The granulations then become 
more velvety, red, prominent, and diffused in appearance (hence the 
" diffuse trachoma" of Stellwag), and are often divided by deep 
chinks. They are, therefore, less distinguishable from the papillse, 
especially as the latter often assume a brownish-red color, and their 
epithelial layer becomes somewhat thickened. 

If the development of the granulations cannot be checked, and 
they extend deeply into the stroma of the conjunctiva, the latter 
often contracts, atrophies, and becomes gradually changed into a 
kind of fibrous cicatricial tissue. These changes may even extend 
to the cartilage, and the cicatrices lend a peculiar glistening or ten- 
dinous appearance to the surface of the conjunctiva. "We then see 
the latter occupied by narrow tendinous streaks, the longest and 
most marked generally running parallel to, and about one line from, 
the edge of the lid. Other tendinous streaks extend in a reticu- 
lated manner towards the retro-tarsal fold. But if the atrophy of 
the conjunctiva and cartilage is very considerable, the bloodvessels 
gradually become obliterated, and the surface of the conjunctiva 
then assumes a pale, waxy, uniformly tendinous appearance ; the 
papillae, follicles, and finally the Meibomian glands becoming de- 
stroyed. It is important to remember that too free a use of caus- 
tics (especially the nitrate of silver in substance or in strong solu- 
tion) will destroy the delicate structure of the conjunctiva, and 
produce more or less extensive cicatrices. 

These changes often extend to the retro-tarsal fold, which becomes 
contracted and tendinous, so that its free border is shortened and 
rounded. It no longer springs into folds at the point where it is 
reflected from the lid on to the eyeball, but, on account of this 
shortening, it passes almost straight on, so that the fold or cul de sac 
which should exist at this point is obliterated. This condition has 
been termed symblepharon posterius. If it is very considerable, 
the lids cannot be completely closed, and thus a certain degree of 
lagophthalmos may be produced. 

These changes in the conjunctiva are of course accompanied by 
an alteration and diminution in its normal secretions, so that its 
surface becomes dry, rough, and scaly. This dryness (xerophthal- 
mia) is often increased by the narrowing or even obliteration of the 
ducts of the lachrymal gland by the inflammation of this portion 
of the conjunctiva. 

On account of the atrophy and contraction of the conjunctiva and 
tarsal cartilage, the latter becomes shortened and incurved. If this 
be but slight, it may only produce an inversion of the eyelashes 
(trichiasis), which now sweep and rub against the surface of the 
cornea. This inversion may be confined to one portion of the 
lashes, or extend to the whole row. If the contraction of the carti- 
lage is considerable, not only the eyelashes, but the free edge of the 
lid will be rolled in, and thus an entropion will be produced. The 
constant friction of the lashes and the edge of the eyelid against the 



7-t DISEASES OF THE CONJUNCTIVA. 

cornea irritates the latter, and soon gives rise to superficial vascu- 
lar corneitis (pannus). This pannus may be termed " traumatic" 
(Arlt), being produced by the friction of the inverted lashes, or of 
prominent granulations or papillae, etc., in contradistinction to the 
pannus which is due to an extension of the granulations on to the 
cornea. The differential diagnosis between these two forms is 
generally not difficult. In the latter, we can trace the extension 
of the disease from the ocular conjunctiva on to the cornea. Small, 
round, elevated, gray infiltrations are formed on its surface just 
beneath the epithelium, and extend over a considerable portion or 
even the whole of the cornea. Between these little nodules, blood- 
vessels appear in more or less considerable number. These infiltra- 
tions often leave behind them depressions or small ulcers on the 
surface of the cornea. The traumatic pannus almost always com- 
mences at the upper portion of the cornea, extending from the 
periphery. This is due to the fact, that the granulations are gene- 
rally more prominent, and trichiasis is more frequent in the upper 
lid than in the lower. The pannus frequently remains confined to 
the upper portion of the cornea, the lower continuing transparent. 
Besides the incurvation of the edges of the lids and consequent 
entropion, we often find that the palpebral aperture becomes much 
shortened (blepharophymosis) in chronic granulations. The pres- 
sure thus exerted on the eyeball increases any existing pannus, and 
greatly retards the cure of the granulations. 

Chronic granulations occur most frequently in adults, and are 
but seldom met with in children or the very aged. Both eyes 
generally become affected either at the outset, or after a time. It 
has been maintained by some ophthalmic surgeons of eminence 
(more especially Arlt), that the disease is often due to consti- 
tutional causes, particularly scrofula. This does not, however, 
appear to be the case, although it must be conceded, that it is 
frequently met with in weakly, cachectic, and scrofulous individ- 
uals. But ill-health is, I think, rather the effect than the cause, 
for the very protracted course of the disease is sure to tell more or 
less severely upon the health and spirits of the patient. 

Defective hygiene and contagion are also the chief causes of 
chronic granulations. The muco-purulent discharge is very con- 
tagious, and may reproduce a similar affection, or it may cause 
catarrhal, purulent, or even diphtheritic ophthalmia, just as, con- 
versely, these diseases may produce granular lids. 

It is probable that, as in purulent ophthalmia, the disease may 
also be propagated by the air, more especially if it is accompanied 
by severe purulent discharge, and the cases are crowded together 
in small, close, ill-ventilated rooms. The disease may occur epi- 
demically and endemically. It spreads rapidly amongst the in- 
habitants of closely-crowded dwellings, such as barracks and 
workhouses. It is very prevalent amongst certain nationalities, 
where the people are crowded together for a length of time in small 
dirty cabins, filled, perhaps, with smoke and ammoniacal exhala- 



CHRONIC GRANULATIONS. 75 

tions. Thus it is very common amongst the poorer Irish, and also 
amongst the Russian peasants (Wecker). 

The -prognosis of chronic granular ophthalmia may be favorable, 
if the granulations have been but limited in number, and the 
patient has been treated from the outset. It must, however, be 
always remembered that the course of the disease, even in the most 
favorable cases, is apt to be very protracted. This will be more 
especially the case, if the granulations have appeared in consider- 
able quantity ; if they have invaded the stroma of the conjunctiva, 
and if there is a tendency to relapses. For then serious compli- 
cations, such as trichiasis, entropion, and pannus, are likely to 
occur, and will not only aggravate the symptoms, but greatly re- 
tard the cure. 

In the treatment of this disease, our first care must be to place 
the patients under the most favorable sanitary conditions. They 
should take a good deal of out-door exercise, their eyes being pro- 
tected against wind, dust, and bright light by blue glasses. They 
should be warned not to expose themselves to any irritating causes, 
as, for instance, tobacco smoke. I have often known the disease 
aggravated and kept up by the patient spending much time in a 
room filled with tobacco smoke. For this reason no smoking 
should be allowed, except in the open air, and theft only to a 
limited extent. The general health must also be attended to. 
Not only may the patient be naturally weak and feeble, but the 
severity and protracted course of the disease are but too likely to 
affect the health, and at the same time to exercise a most depress- 
ing influence upon the mind. The diet should be nutritious, and 
easily digestible, and malt liquor and wine will generally be very 
beneficial. If the patient is scrofulous, or weak and feeble, cod- 
liver oil, steel, and quinine should be freely given, and every care 
taken to invigorate the constitution as much as possible by open 
air exercise, sea-bathing, or even a voyage. 

In. our local treatment we must be chiefly influenced by the fact, 
that the maintenance of a certain degree of inflammation of the 
conjunctiva is necessary. and desirable, in order to produce and 
hasten the absorption of the granulations. Our chief efforts must, 
therefore, be directed to maintain the requisite degree of inflam- 
mation, and so to balance it that it shall not on the one hand be 
too considerable, nor on the other too slight for promoting the ab- 
sorption. 

The greatest stress must be laid upon the fact, as Arlt and Stro- 
meyer remind us, that the purpose of the cauterization is not that 
of chemically destroying the granulations, for this would lead to 
great and lasting injury of the conjunctiva from the destruction of 
its secreting organs, and the formation of dense cicatrices ; but, its 
object is to maintain a certain degree of hypersemia and inflam- 
mation of the conjunctiva, in order to hasten the absorption of the 
granulations. The nature and strength of the caustic must vary 
with the effect we desire to produce. If there is much swelling 
of the conjunctiva and papillae, together with a thick, copious muco- 



76 DISEASES OF THE CONJUNCTIVA. 

purulent discharge, the crayon of nitrate of silver and potash should 
be applied, its effect being at once neutralized by the solution of 
salt and water. The cauterization may be repeated every 48 hours. 
If the patient cannot be seen sufficiently frequently for this, he 
should use a collyrium of nitrate of silver (gr. ij — iv ad §j), or of 
sulphate of copper of the same strength, two or three times daily. 
In these cases we may also first try the effect of a collyrium of 
acetate of lead, gr. ij — iv ad gj, or the chlorine water, in order to 
see if the conjunctiva will bear the nitrate of silver. The use of 
very strong solutions of nitrate of silver (gr. x — xx ad gj) are not 
judicious, as they are but too likely to destroy the granulations, 
and with them the normal structure of the conjunctiva, instead of 
simply favoring their absorption. I think the crayon of nitrate of 
silver or copper is always to be preferred to the use of collyria, as 
we can regulate and limit the effect of the cauterization according 
to our wish, confining it, if necessary, chiefly or entirely to certain 
portions of the conjunctiva. If there is considerable swelling of 
the conjunctiva, especially at the retro-tarsal fold, superficial scari- 
fication may be employed with much advantage. After the 
cauterization, cold compresses should always be applied to the 
eyelids, in order to diminish the inflammatory reaction ; or the 
cold douche or pulverizer may be employed. If the conjunctivitis 
is so slight as not to produce the absorption of the granulations, 
but rather to encourage their development, it will be necessary to 
increase the hypersemia and inflammatory swelling of the con- 
junctiva. The repeated application of sulphate of copper in sub- 
stance is very effectual for this purpose. The same effect may 
also be produced by the application of warm compresses over the 
eyelids. Von Graefe 1 has found this treatment very successful, 
especially in those cases in which the granulations tend to extend 
deeply into the conjunctiva, and in which there is not a sufficient 
degree of hyperaemia and swelling of this membrane. These warm 
compresses should, however, only be applied for a limited period, 
otherwise they may produce too considerable an inflammation and 
too great an irritability of the eye. 

In treating chronic granulations, it will be necessary occasionally 
to change the caustic, as it loses its effect after a time, from the 
conjunctiva becoming accustomed to it. Thus alum, acetate of 
lead, or tannin, may be substituted with advantage for the nitrate 
of silver and sulphate of copper. Some patients are more bene- 
fited when the astringent or caustic is applied in the form of an 
ointment than of a collyrium. If it is, therefore, found in obstinate 
cases of chronic granulations or chronic ophthalmia that the 
various collyria are doing but little good, an ointment must be 
substituted for them, containing sulphate of copper, nitrate of 
silver, or acetate of lead. The strength of the ointment must 
vary with the severity of the case, but as a rule it is best to 
employ it rather weak at first, for fear of setting up too much 

1 "A. f. O.," yi. 2, 147. 



CHRONIC GRANULATIONS. 77 

irritation. The following proportions will be found most generally 
useful : 1. Cupri sulph. gr. j — iv ad §j axung. 2. Argent nitrat. 
gr. ss — iij ad Jj. 3. Plumb, acet. gr. iv — xij ad 3j. The glycerine 
plasma may be substituted for the lard. A small portion (about 
the size of a split pea) of the ointment should be placed with a 
probe or the end of a quill on the inner side of the lower lid; the 
eye is then to be closed and the lids rubbed over the globe, so that 
the ointment may come in contact with the whole conjunctival 
surface. Great care must be taken never to order any preparation 
of the salts of lead if there is any abrasion of the epithelium of 
the cornea or any ulcer of the latter, as it will produce an indelible 
lead stain. Hairion 1 strongly recommends the use of tannin in 
cases of chronic ophthalmia, etc. etc. He employs it in two forms, 
as a collyrium and as a mucilage. The former contains about 12 
grs. of tannin to gj of distilled water, and is chiefly indicated in 
cases of catarrhal ophthalmia. The mucilage is much stronger 
and is employed in chronic granulations, chronic ophthalmia, 
pannus, etc. It is to be prepared in the following manner : One 
part of tannin, is to be dissolved in four parts of water and this 
solution strained through fine muslin, then two parts of gum 
arabic are added and the whole carefully mixed and worked up 
into mucilage. A small quantity is to be applied with a fine 
camel's hair brush to the conjunctiva of the lower lid. In chronic 
granulations, etc., and chronic ophthalmia much benefit is often 
derived from the application of astringents and caustics to the 
external surface of the lids. Thus a solution of nitrate of silver 
(gr. iv — viij ad 3j) may be painted over the external surface of the 
upper lid, or a compress of lint dipped in it and laid over the 
closed lids. Care must, however, be taken that the solution is not 
too strong or repeated too often, otherwise it may easily stain the 
skin. Compresses soaked in either of the following lotions and 
laid over the closed lids will also be found very beneficial: 1. 
Liq. plumb, diacet. 3j ; aq. dest. giv. 2. Liq. plumb, diacet. 3j ; 
boracis 9ij ; aq. amygdal. amar. (Prussian Pharmacopoeia) iss ; aq. 
dest. gvj. These compresses are to be changed every 3 — 4 minutes 
and continued for 20 — 30 minutes, this being repeated two or three ( 
times daily. In some cases, the acetate of lead should be rubbed ' 
in (finely powdered) between the granulations. This treatment, 
which was first adopted by Buys, 2 has been practised with great 
success, especially in Belgium. I have employed it with much 
benefit in those cases in which, together with but a slight secre- 
tion and lachrymation, the granulations are prominent and fleshy, 
being arranged in rows, with deep furrows or chinks between 
them. Finely powdered acetate of lead should be freely rubbed 
into these furrows until they are quite filled up. The effect of 
this is, so to speak, to choke the granulations, their vitality is 
impaired, and they gradually dwindle down in size and disappear. 

1 French Translation of Mackenzie, I, p. 753. 
French Translation of Mackenzie's Treatise, 1, 748. 



78 DISEASES OF THE CONJUNCTIVA. 

After the application, the conjunctiva looks marbled or tattooed of 
a red and white color, the chinks are filled up, and it soon becomes 
smooth and even. An important fact in connection with this 
treatment is, that the discharge is now no longer contagious ; at 
least in Belgium it is always considered, when the acetate of lead 
has been rubbed in, that the patients may go with impunity, 
amongst healthy persons ; so that soldiers affected with granular 
lids need no longer be confined and separated from the others, but 
may, if they are able, resume their duties without danger of 
spreading the disease. The acetate of lead is best applied in the 
following manner : The eyelids having been thoroughly everted 
and the retro-tarsal fold brought well into view, a small portion of 
very finely powdered acetate of lead is then taken up in a small 
curette and dusted over the granulations, being well rubbed into 
the chinks so as to fill them up. The watery discharge from the 
conjunctiva changes the powder into a thin plasma, which runs 
through and fills up the furrows between the granulations. When 
it has been applied to every portion of the granular conjunctiva, a 
small stream of cold water, either from a sponge or an India-rubber 
ball syringe, should be made to play upon the conjunctiva, in 
order to wash away any superfluous quantity of the powder, 
which comes away in small white flakes. Both eyelids may be 
everted at the same time, so as to fold over and protect the cornea, 
the powder being rubbed over both eyelids, and the stream of 
water applied before they are replaced. But if the simultaneous 
eversion of both lids is difficult, or the patient very restless and 
unruly, it is better to evert one lid at a time. It is best to com- 
mence with the lower lid, for if the lead be applied first to the 
upper, the lower becomes reddened and bathed in tears, so that it 
will not only be difficult to see the chinks, but the powder will be 
readily washed away by the tears, whereas the conjunctiva of the 
upper lid, from its greater expanse, can be more readily dried, and 
the tears are hence of less inconvenience. 

Directly after the application, there is an increased flow of tears, 
the ocular conjunctiva becomes injected, and this is accompanied 
perhaps by considerable irritation, heat, and smarting in the eye, 
but these symptoms will soon yield to the application of cold com- 
presses. In about half an hour, the lids should be everted and the 
conjunctiva again washed by a stream of water, in order that any 
remains of the lead may be removed. The conjunctiva will now 
be more smooth and even, the chinks between the granulations 
being filled up aiid obliterated by the powder. If the application 
has been insufficient or too superficial, the granulations will reap- 
pear after a time and increase in size and prominence, rendering a 
fresh application of the remedy necessary. If the acetate of lead is 
carefully applied and the surplus well washed away, I cannot say 
that I have ever seen any disadvantage arise from its employment, 
nor have I found that it roughens the lids and thus irritates the 
surface of the cornea. The best mode of applying the solution of 
the acetate of lead is to evert the lids, and after" drying the con- 



CHRONIC GRANULATIONS. 79 

junctiva with a piece of linen, to apply it with a small brush to the 
granulations, this being neutralized after a few seconds with tepid 
water. The strength of the solution should vary from 6 to 10 or 
20 grains to the ounce, according to the condition of the conjunc- 
tiva, and it should be applied every day or every other day. 

I must strongly object to the application of undiluted liquor 
potassse to the granulations, as this not only more or less destroys 
the stroma of the conjunctiva, but gives rise to very considerable 
cicatrices, leading to entropion, etc. 

Should any ulcers of the cornea exist, the treatment of the con- 
junctivitis by caustics must be continued, but atropine should be 
applied in the intervals. The application of a firm compress band- 
age often acts very advantageously in checking the growth of the 
granulations, and hastening their absorption ; but other local reme- 
dies must be at the same time applied. It has even been suggested 
to keep up a considerable degree of compression by ivory plates ad- 
j usted to the lids. 1 

The treatment of the pannus must vary according to its cause, 
its degree, and length of existence. If it be dependent upon the 
friction of inverted lash'es, prominent granulations or papilla?, or 
upon entropion, these affections must be treated, and when they are 
cured, the pannus will soon disappear. But if the granular lids and 
the pannus have become very chronic, they may set an obstinate 
defiance to the most varied treatment. Caustics and stimulant 
applications of every kind may be tried, and yet the disease prove 
intractable. In some cases, in which the pannus was not too dense 
and vascular, I have found considerable benefit from a collyrium 
composed of 1 part of oil of turpentine to 2 or 4 parts of olive oil. 
A drop of it should be applied once or twice daily to the inside of 
the lid. This collyrium was, I believe, first recommended by 
Donders. If, on the disappearance of the pannus, we find the cur- 
vature of the cornea considerably altered, or a central opacity 
remaining, it may be necessary to make an artificial pupil either by 
an iridectomy or an iridodesis. If the palpebral aperture is much 
shortened, and the eyelids thus press on the eyeball, the outer can- 
thus should be divided with a pair of scissors, so as to widen the 
opening of the lids and relieve the pressure. (Vide operation of 
Canthoplasty.) 

Von Graefe 2 has found great benefit from chlorine water in cases 
of even severe complete pannus. He especially mentions two cases 
in which the pannus was so advanced that the patients could only 
distinguish light from dark, and were quite unable to count fingers. 
In both, not only had various caustics, such as nitrate of silver, 
sulphate of copper, acetate of lead, been applied for many months 
without avail, but syndectomy had been performed, and in one in- 
oculation, without any beneficial result. After using the chlorine 

1 Vide Dr. Stokes's paper on this subject. "Dub. Quart. Journal Med. Sci." 
xli. 38. 
* "A. f. O.," x. 2, 198. 



80 DISEASES OF THE CONJUNCTIVA. 

water for six or eight weeks, they were both so much improved as 
to be able to find their way about tolerably well. In other, less 
severe, cases of pannus, he has also experienced much benefit from 
its use. The chlorine water is either to be used as a collyrium and 
dropped into the eye once or twice daily, or it is to be lightly 
brushed over the everted conjunctiva. 

For very inveterate cases of pannus, more especially if it only 
involves a portion of the cornea, syndectomy may be tried. This 
operation, which was first introduced by Dr. Furnari, 1 proves use- 
ful in cases of inveterate pannus, in which a portion of the cornea 
is clear, so that it would not be safe to perform inoculation, or, 
if the latter is for some reason inapplicable in cases of complete 
pannus. The. object of the operation is to cut off the supply of 
blood from the cornea by a division and part removal, not only of 
the conjunctival, but also of the subconjunctival vessels. It is a 
less dangerous and troublesome proceeding than inoculation. It 
must, however, be also admitted that it is not always successful, 
the cases improving perhaps somewhat at first, and then a relapse 
takes place. 

Syndectomy is to be performed in the following manner : The 
patient should be placed thoroughly under the influence of chloro- 
form, as the operation is very painful and protracted, and the eye- 
lids should be kept apart by the stop speculum. The operator then 
seizes with a pair of forceps a portion of the conjunctiva and sub- 
conjunctival tissue, near the cornea, so as to fix the eye steadily. 
He next with a pair of curved scissors makes a circular incision 
through the conjunctiva, all round the cornea, and about an eighth 
of an inch from the edge of the latter, and parallel to it. This cir- 
cular band is then dissected off, and excised close to the edge of the 
cornea, so that a wide circle of conjunctiva may be removed all 
round the cornea. For the purpose of more easily rotating the 
eye, two small portions of conjunctiva should be left standing near 
the cornea until the operation is completely finished, when they are 
to be snipped off. A circular portion of the subconjunctival tissue, 
corresponding to the wound in the conjunctiva, is next to bo re- 
moved, quite close to the sclerotic, so as to bare the latter com- 
pletely ; if small portions of subconjunctival tissue remain adhering 
to it, they may be scraped off with the edge of a cataract or iridec- 
tomy knife. Some of the larger vessels upon the cornea may also 
be divided near its edge. Dr. Furnari advises that the exposed 
sclerotic should be cauterized with nitrate of silver. This is, how- 
ever, a most dangerous proceeding, as it is but too likely to produce 
inflammation and sloughing of the sclerotic and cornea. Cold com- 
presses should be applied until the symptoms of inflammatory re- 
action have subsided. These are, as a rule, but moderate, and the 
photophobia, pain, and lachrymation generally disappear in about 

> "Gazette Medicale," 1862, No. 4, etc. ; vide also an Article upon the subject 
by Mr. Bader, " Roy. Lond. Ophth. Hosp. Reports," iv. 22. This operation has 
received various names ; at one time it was termed Circumcision of the cornea. It 
is now generally called either Syndectomy or Peritomy. 



CHRONIC GRANULATIONS. 81 

48 or 60 hours. It is wise to keep the patients in the hospital for 
a few days, so that, if severe inflammatory symptoms should super- 
vene, they may be treated at once. 

In those cases of inveterate pannus in which the latter is thick, 
very vascular, and covers the whole of the cornea, and in which, on 
account of the cicatricial changes in the conjunctiva, it is impossi- 
ble to excite sufficient hypersemia and swelling of the conjunctiva 
for the absorption of the granulations, it may be necessary to pro- 
duce a purulent inflammation of the conjunctiva by the inoculation 
of pus, in order that the granulations may, if possible, be absorbed 
and the cornea cleared during the progress of the inflammation. 
This proceeding, which was first advocated by Piringer, has long 
been extensively and successfully practised in Belgium, where 
granulations are very common amongst the soldiers. In England 
it has also been very largely and successfully employed at the Royal 
London Ophthalmic Hospital, Moorfields, where Mr. Bader first 
introduced it. I have seen many admirable cures produced by it, 
and patients restored to the enjoyment of excellent sight (some 
being able to read Eo. 1. of Jager) who had been suffering from so 
dense a pannus that they were unable even to count fingers. In 
many of these cases most other remedies had been tried without 
avail. The chief danger is, of course, that the purulent inflamma- 
tion which is induced should be so severe as to produce suppura- 
tion of the cornea and loss of the eye. But it is surprising what a 
degree of inflammation a very vascular and completely pannous 
cornea will bear with impunity, and be, perhaps, finally restored to 
almost normal transparency. It may be laid down as a rule, that 
the more vascular the cornea, the less danger is there of its slough- 
ing, for the numerous bloodvessels on its surface will maintain its, 
vitality during the purulent inflammation. Inoculation is, there- 
fore, much less safe where the vascularity of the cornea is but 
moderate, and is inadmissible if a portion of it remains transparent. 
Another danger of inoculation is, that the matter, instead of set- 
ting up purulent ophthalmia, may give rise to diphtheritic conjunc- 
tivitis. Happily this danger is but very slight in England, but we 
have seen that, in certain parts of the continent, more especially 
Berlin, this affection is but of too common occurrence, and that the 
mild forms of conjunctivitis often produce the most virulent form 
of diphtheritic ophthalmia. For this reason, it is there hardly safe 
to inoculate a, case of pannus with even the mildest purulent matter, 
for we have no guarantee that it may not give rise to diphtheritis. 
Von Graefe has called special attention to this fact, and has been 
obliged, in consideration of so great a risk, to abandon almost 
entirely the employment of inoculation in the treatment of pannus. 
In England the occurrence of diphtheritis is extremely rare, and I 
have not seen a single case of inoculation in which it has ensued. 

Many surgeons are still very much afraid of inoculation, but I 

think, when we consider how utterly hopeless most cases of severe 

chronic pannus are, that we are justified in strongly recommending 

the patient to run some slight degree of risk for the chance of 

6 



82 DISEASES OF THE CONJUNCTIVA. 

obtaining a useful amount of sight. I do not, therefore, hesitate 
to employ it in cases of inveterate, complete, vascular pannus, in 
which the other remedies have been tried without avail, for in 
such we must admit that it is our last resource, and that no other 
chance of restoring the sight remains. 

Care must, however, be taken in the choice of the purulent matter, 
and in regulating its strength according to the exigencies of the 
case. The more dense and vascular the pannus,. the stronger may 
the matter be. The best and safest is that obtained from the eyes 
of an infant suffering from purulent ophthalmia, more especially 
if the disease is in its decline, and no affection of the cornea, or 
only a very slight one, exists. Yellow pus is more active and 
powerful than the whitish discharge, as is also that taken from 
the eye during the acute stage of the disease. 

The matter from an eye suffering from inoculation is stronger 
than that from an infant, as its activity appears to be increased by 
the inoculation. Gonorrhceal matter is far too strong and dan- 
gerous. Even in the worst cases, I prefer the whitish discharge 
from an infant. Mr. Lawson, who has had very great experience 
in this subject of inoculation, has also very justly pointed out, 1 
that in using gonorrhceal matter there is the risk of its being 
tainted by the syphilitic virus through a chancre perhaps existing 
in the urethra. 

The mode of inoculation is as follows: A drop of pus from the 
eye of an infant affected with purulent ophthalmia is to be placed 
with the tip of the finger (or a camel's hair brush) on the inside of 
the lower eyelid, and left there. Within 24 hours of the inocu- 
lation, the eyelids generally begin to swell and become cedematous, 
often to a very considerable degree ; this is accompanied by more 
or less irritability of the eye, photophobia, and lachrymation. In 
the course of three or four days all the symptoms of an acute puru- 
lent ophthalmia set in, together with a copious, thick, creamy 
discharge. The disease mostly runs its course in from three to 
four weeks, by the end of which time the cornea is generally much 
more clear, and. the granulations diminished. This improvement, 
however, continues to increase for many weeks, or even months. 
]STo treatment is to be adopted for checking the course of the in- 
flammation. After the second or third day, the patient may be 
permitted to wipe away the discharge with a sponge or a bit of 
linen, so as to cleanse the eye. But however severe the inflamma- 
tion may be, it must be allowed to run its course unchecked by the 
use of astringent or caustic lotions. 

One eye should be inoculated at a time, the other being carefully 
closed by the hermetic collodion compress. This must be more 
especially done if this eye is sound. Indeed, in such case it may 
De a question whether the diseased eye should- be inoculated at all, 
for fear that, through any mischance or carelessness, the healthy 
eye should become affected. In deciding this point, we must be 

1 "Roy. Lond. Ophth. Hosp. Reports," iv. p. 183. 



PHLYCTENULAR OPHTHALMIA. 83 

chiefly guided by individual considerations. The compress should 
be removed every day, in order that the eye may be washed and 
cleansed, during which process, of course, the greatest care must 
be taken that no matter gets into it. 

A very interesting and important fact has been pointed out by 
Mr. Lawson, 1 viz., that a preliminary syndectomy appears to render 
the inoculation a safer proceeding, for, the conjunctiva and subcon- 
junctival tissue having been removed from around the cornea, the 
intensity of the inflammation at this point is greatly diminished, 
and the cornea less apt to suffer. In cases, therefore, in which the 
pannus is not very vascular, or does not involve the whole of the 
cornea, and where, therefore, inoculation might prove dangerous, 
it would be advisable to precede it by a syndectomy, and then, 
when the eye has quite recovered from this, to employ inoculation. 



8.— PHLYCTENULAR OPHTHALMIA. 

The disease is generally ushered in by a feeling of heat and itch- 
ing in the eyelids, and a watery and irritable condition of the eye. 
These symptoms of irritation increase until there may be a very 
considerable amount of photophobia, lachrymation, and pain in and 
around the eye (ciliary neuralgia). The latter, however, is never 
so severe when the phlyctenule are confined to the conjunctiva, as 
when they also invade the cornea. There is also more or less con- 
junctival and subconjunctival injection, the degree and extent of 
which vary with the intensity and extent of the disease. Some- 
times the injection is only partial and confined to a certain portion 
of the ocular conjunctiva. We then notice a triangular, fan-like 
bundle of conjunctival vessels, extending from the retro-tarsal region 
towards the edge of the cornea. The base of the triangle is turned 
towards the palpebrse, and the apex is at the cornea. Beneath the 
conjunctival injection is observed a corresponding rosy zone of sub- 
conjunctival vessels. At this spot there is also generally a slight 
cedematous swelling of the conjunctiva (serous chemosis). At the 
apex of the triangle of vessels, one or more small herpetic vesicles 
or pustules make their appearance, which are semi-transparent, or 
of a yellowish- white color, and about the size of a small millet seed.. 
They are especially apt to occur at the outer side of the cornea, and 
are often symmetrical, being formed at the outer side o£ each eye. 
The epithelium which covers the phlyctenula is soon shed, leaving 
a small excoriation or ulcer, which gradually dwindles down and 
becomes completely absorbed. In other cases, the ulcer increases 
somewhat in size and depth, and its contents become yellow and 
opaque; but after a time it is covered again by epithelium, and its 
contents then gradually undergo absorption. With the appearance 
of the phlyctenula,* the symptoms of irritation generally diminish,, 
especially when the epithelium is shed and the contents of the vesi- 

1 "Roy. Loud. Ophth. Hosp. Reports," iv. p. 185. 



84 DISEASES OF THE CONJUNCTIVA. 

cle escape. As the latter is being absorbed the vascularity decreases, 
but at the same time the conjunctiva may become somewhat swol- 
len, especially in the retro-tarsal region, and this is accompanied by 
a muco-purulent discharge; so that we have in fact a combination 
of catarrhal and phlyctenular ophthalmia. The affection may, how- 
ever, have this mixed character from the outset. 

If the phlyctenule are not confined to one portion of the ocular 
conjunctiva, but are scattered about on various parts of it, in per- 
haps considerable numbers, the vascularity is diffuse and well- 
marked. The symptoms of irritation are more pronounced, and 
the ciliary neuralgia, lachrymation, and photophobia greater. The 
latter, indeed, is sometimes excessive in phlyctenular ophthalmia, 
more especially in scrofulous children, and is often quite dispropor- 
tionate to the amount of the vesicles. The phlycteuulse frequently 
form at the edge of the cornea, surrounding it like a row of beads, 
or they occur at the limbus conjunctiva?, lying partly on the cornea 
and partly on the conjunctiva. Very often the affection appears 
simultaneously on the conjunctiva and the cornea. The pustules 
sometimes increase considerably in size and depth, the inflamma- 
tion extending to the subconjunctival tissue (episcleritis), and even 
perhaps to the superficial layers of the sclerotic. The correspond- 
ing portion of the conjunctiva and subconjunctival tissue are then 
often very vascular, and considerably thickened and swollen, so 
that the pustules appear situated upon a prominent base. The 
vascularity (especially of the subconjunctival tissue) is of a pecu- 
liar dusky, bluish-red tinge, which is very easily recognized. This 
form is extremely protracted and very prone to relapses, so that 
many months may pass before it is cured. "When the pustules are 
very numerous, it has been termed pannus herpeticus. 

The prognosis of phlyctenular ophthalmia is generally very favor- 
able, especially if the case is seen early; if the phlyctenulse are few 
in number and limited to one portion of the conjunctiva; if the 
cornea is not affected, and there is no episcleritis. In favorable . 
cases, the disease generally runs its course in from ten to fifteen 
days, and disappears without leaving any trace behind it. Very 
mild cases, in which only one or two small phlyctenulse form near 
the edge of the cornea without much irritability or vascularity of 
the eye, may even be cured in five or six days, simply by a few 
insufflations of calomel, without any other treatment whatever. 
The chief .source of trouble and annoyance is the great tendency to 
relapses. Perhaps j ust as the disease seems to be all but cured, fresh 
symptoms of irritation supervene, and a new crop of phlyctenule 
appear. If the disease then becomes complicated with episcleritis, 
its course may be very obstinate and protracted. 

Phlyctenular ophthalmia occurs by far most frequently amongst 
children, especially those of a feeble, scrofulous habit, and of a 
highly nervous excitable temperament. Stellwag is of opinion that 
local irritants acting upon the ciliary nerves may give rise to it ; 
as, for instance, the premature and excessive use of strong astringent 
collyria in some ophthalmia?, whilst the irritability of the eye is 



PHLYCTENULAR OPHTHALMIA. 85 

still very great. The irritation may also be propagated from other 
branches of the fifth to the ciliary nerves, as in cases of eczema, 
impetigo of the cheek, the mucous membrane of the nose, etc. 
Indeed, he thinks that the disease is of an herpetic nature, and 
hence terms it " herpes conjunctivae." Some of its varieties do not, 
however, bear any resemblance to herpes in their course. 

The treatment must be especially directed to the following points : 
to diminish the irritability of the eye, to prevent any graver com- 
plications, to hasten the absorption of the phlyctenulse, to prevent if 
possible the occurrence of a relapse, and to improve and strengthen 
the patient's general health. 

If the photophobia is very considerable, a compress of charpie 
should be applied to the eye. This will prevent the constant fric- 
tion of the lids against the eyeball, which greatly increases the 
irritability, and impedes the regeneration of the epithelial layer 
over the vesicle or ulcer. This point should be more especially 
attended to if the phlyctenulse occur on the cornea, for then, as 
we shall see hereafter, if their epithelial covering is shed, the 
denuded nerve fibres of the cornea are exposed, and this frequently 
gives rise to great irritability of the eye, and the most intense pho- 
tophobia, these symptoms often rapidly disappearing as soon as the 
phlyctenulse are again covered by epithelium. In children the 
compress is especially useful, for it prevents their constantly rub- 
bing the eyes with their hands, which greatly aggravates the irri- 
tability. Moreover, the compress diminishes the lachrymation, 
soaks up the tears, and thus prevents their flowing over the cheek, 
which often gives rise to excoriations and eczema of the lower 
eyelid and cheek. The compress should be changed every four or 
five hours, the eye washed with lukewarm water, and the crusts 
removed from the edges of the lids. If the latter are excoriated, 
a little simple cerate or weak nitrate of mercury ointment should 
be applied to them. The same remedies are to be applied to the 
nostrils if they are excoriated, or a small dossil of lint soaked, in 
olive oil should be inserted into them. If there is much thick dis- 
charge from the nose, the inside of the nostril should be lightly 
touched with a finely pointed crayon of nitrate of silver. Lie- 
breich 1 strongly recommends the " Eau de Labarraque" (a solution 
of soda impregnated with chlorine gas) for this purpose. If the 
lower lid and cheek are much excoriated and eczematous, a little 
violet powder should be dusted over the sores, or we may use the 
following powder: Zinc. oxid. 9j — ij, Pulv. amyl. ,?ij. The follow- 
ing lotions will also be found very serviceable: Plumb, acetat. gr. 
x, Glycer. 3ij — 3ss, Aq. destill. §vj, to be applied three or four 
times daily. Instead of the acetate of lead, borax (Jij) may be 
employed. Atropine drops must be applied three or four times a 
day, but if they are found rather to increase than allay the irri- 
tability of the eye, a belladonna collyrium (Ext. bellad. 3ss ad aq. 
destill. gij) must" be substituted for them. The compound bella- 

' "Klin. Monatsbl.," 1864, p. 393. 



86 DISEASES OF THE CONJUNCTIVA. 

donna ointment should be rubbed over the corresponding half of 
the forehead three or four times daily, until a slight papular erup- 
tion is produced. When the symptoms of irritation have subsided, 
we must have recourse to the insufflation of calomel, and the appli- 
cation of the red precipitate ointment, two remedies which may 
be regarded as specifics for phlyctenular ophthalmia. Indeed the 
calomel often acts as a charm, frequently causing a well-marked 
phlyctenula, together with the accompanying vascularity, to dis- 
appear completely in the course of two or three days. It should 
not be applied whilst there is much vascularity, photophobia, or 
lachrymation, as it is apt to prove too irritating, but when these 
symptoms have subsided, it should be tried in very small quantity 
at. first, so that we may feel our way. Its beneficial effect appears 
to be chemical, and not that of a simple mechanical irritant, for 
experiments made with other finely powdered substances (sugar, 
magnesia, etc.), proved ineffectual. It is supposed to act on the 
Meibomian glands or on the epithelial cells of the conjunctiva. 
Donders has found that after its use some of the smaller conjunc- 
tival vessels appear to become obliterated. 

The calomel should be finely powdered and perfectly dry, so that 
it does not form clot3 on the conjunctiva or cornea, for these would 
act as mechanical irritants. It should be applied with a small 
camel's hair brush, held lightly between the forefinger and thumb ; 
and a slight quick fillip with the middle finger will readily jerk 
some of the powder into the eye. Care should be taken not to dust 
in too much, more especially at first, otherwise it may produce a 
good deal of irritation. It should be applied every day or every 
other day, according to the requirements of the case, but if the lids 
become much gummed together in the evening, it should be em- 
ployed less frequently. It is an excellent remedy to prevent re- 
lapses, and should, therefore, be continued for eight or ten days 
after the disease is cured. I am in the habit of directing the pa- 
tients to reapply it at once, if they experience any renewed irrita- 
tion -in the eye, for its timely use will generally succeed in cutting 
short a renewed attack of the disease. 

In children, it is often very difficult to apply any remedy to the 
eye, on account of their great restlessness, or the intense spasm of 
the eyelids. In such cases, the head of the patient should be placed 
between the knees of the surgeon, who is to be seated ; in this way 
it can be firmly and steadily fixed; an assistant seated on a chair 
opposite should hold the child's arms and legs. The surgeon should 
then open the eyelids with Desmarres' broad silver elevator, which 
will enable him to obtain a thorough view of the eyeball, and to 
apply any remedy. By adopting this plan much time and trouble 
will be saved, and the eye less irritated than by repeated ineffectual 
attempts to examine it. 

The red precipitate ointment is also an excellent remedy. Al- 
though it has long been employed in ophthalmic practice, we are 
indebted to Pagenstecher for the more accurate indications as to 
its use, and for showing the advantage of employing it in consider- 



PHLYCTENULAR OPHTHALMIA. 87 

ably stronger doses than was formerly done. He has more lately 
substituted the yellow amorphous oxide of mercury for the red 
oxide, which is in the finest possible state of division, and, being 
entirely free from any crystalline form, does not adhere by any fine 
points to the conjunctiva. 1 He uses an ointment of very consider- 
able strength, viz., half a drachm or one drachm of the yellow 
oxide of mercury, to an ounce of lard. 2 I have generally found 
that a much weaker ointment (gr. x. — xxiv to the ounce) was 
equally beneficial, and caused less irritation. It should be applied 
once a day with a small brush to the inside of the eyelids, which, 
on being closed, will sweep off the ointment from the brush. After 
a few minutes it should be wiped off from the lids (between which 
it becomes exuded) with a piece of fine linen. The ointment is 
especially indicated when the symptoms of severe irritation have 
subsided^ but it may even be applied with advantage in the acute 
stage, if care be taken to remove it completely from the conjunc- 
tival sac. It is also of great benefit in checking the tendency to 
relapses. 

In cases in which the phlyctenular ophthalmia is accompanied 
by much swelling of the conjunctiva and symptoms of catarrhal con- 
junctivitis, Von Graefe has found much benefit from chlorine water, 
as it diminishes the catarrhal symptoms, especially the swelling, 
without setting up too considerable a degree of irritation, which is 
the chief danger in employing the nitrate of silver or any strong 
astringents in these cases. It is also indicated in the prominent 
ulcers, accompanied by episcleritis, as it considerably hastens the 
formation of the epithelial covering over the ulcer. Some touch 
the latter with the point of a crayon of nitrate of silver, but this is 
not always free from risk, especially when the ulcer is situated 
near the cornea, and the chlorine water appears to act more bene- 
ficially. 

It is not advisable to apply blisters to the temple, as the skin is 
often extremely irritable, and there is frequently a great tendency 
to eczema. Great attention should be paid to the constitutional 
treatment of the patient. He should be placed upon a nutritious 
and wholesome diet, and be allowed as much exercise in the open 
air as possible. Cleanliness should be strictly attended to, and cold 
bathing insisted upon if the patient is not too weak. Nothing is 
so injurious as to confine him in the dark on account of the pho- 
tophobia, for in this way the eye will become so sensitive that no 
light will be borne. Children are especially prone to seek the dark, 
burying their heads in their mother's lap, or in a sofa or bed in the 
corner of the room, and only the strictest injunctions will make 
them face the light. They should be gradually accustomed to it, 
their eyes being perhaps protected by a shade, or a pair of blue 
glasses. The compress bandage should only be applied if the pho- 

1 " Nassauer Corresp. Bl.," No. 10, 1858. 

2 An interesting and valuable paper, Dr. Pagcnstecher, on the use of this oint- 
ment, will be found in the " Ophthalmic Review," vol. ii. 115 [and in the "Amer. 
Journ. of Med. Sci.," Oct. 1865, pp. 507 and 550]. 



88 DISEASES OF THE CONJUNCTIVA. 

tophobia and lachrymation are very intense, and should be left off' 
when these symptoms of irritation have diminished. 

The use of small doses of tartar emetic as a sedative is often found 
beneficial, more especially if there is much photophobia, the latter 
being frequently very soon relieved by the administration of 10 — 20 
drops of antimonial wine given 3 — 4 times daily. But care should 
be taken not to continue this remedy too long, so as to debilitate 
and weaken the patient, and it should not be persisted in if no im- 
provement takes place in the course of 4 — 5 days. The bowels should 
be kept well regulated, and an occasional purge of rhubarb and 
jalap, or calomel and jalap, should be given, particularly in chil- 
dren. If the children are very irritable, and there is much pain, 
sedatives should be prescribed, e. g., small doses of hyoscyamus, 
conium, or morphia. 

Tonics, more especially quinine, are of .great benefit. This may 
be given in combination with steel, or also with cod-liver oil. In 
infants and young children the liquor cinchonfe or the vinum ferri 
should be administered. 

The photophobia often proves very obstinate and intractable, but 
as a rule less so than when the cornea is also implicated. This 
spasm of the lids (blepharospasm) is a reflex neurosis, due to an 
irritation of the nerves of the conjunctiva and cornea, which pro- 
duces hypersesthesia of the orbicularis muscle {vide blepharospasm). 
The photophobia dependent upon exposure of the denuded nerve 
fibres of the cornea, should, as has been recommended above, be 
treated by the application of a compress. As the health of the 
patient improves, and he becomes more and more accustomed to the 
light, the photophobia will generally disappear. In children it may 
be very advantageous to employ a remedy which I first saw very 
successful in Von Graefe's hands, viz., the dipping their heads 
under water, as this breaks the circuit of reflex action by the in- 
tense fright of the child. This should, if necessary, be repeated 
several times, even at one sitting, until the child opens its eyes 
properly. I have often seen surprising results from this treatment, 
when a,ll other remedies had failed. The head must, however, be ' 
well dipped under water, so that mouth, nose, and eyes are im- 
mersed, the child being kept in this position for a few seconds, 
which will effectually frighten it. 

In adults I have also obtained much benefit in severe blepharo- 
spasm from the subcutaneous injection of morphia in the region of 
the supra-orbital nerve. The division of this nerve will not be ne- 
cessary in the photophobia accompanying phlyctenular ophthalmia. 

9— EXANTHEMATOUS OPHTHALMIA. 

The eyes often become affected in measles and scarlatina. In the 
milder cases the conjunctiva becomes hypersemic, and perhaps symp- 
toms of catarrhal eonj unctivitis supervene. Exceptionally, however, 
the inflammation may assume a more severe muco-purulent cha- 



EXANTHEMATOUS OPHTHALMIA. 89 

racter, leading perhaps to perforating ulcers of the cornea, prolapse 
of the iris and anterior staphyloma ; this is more especially liable 
to occur in children of a weakly, scrofulous diathesis. Not unfre- 
quently the conjunctivitis presents the phlyctenular form, being 
accompanied by much photophobia, lachrymation, and general 
irritability of the eye. Extensive ulcers of the cornea or iritis are 
only of rare occurrence. 

In the majority of cases the treatment need only be very simple. 
The eyes should be guarded against the light, be frequently washed, 
so that any discharge may be cleansed away, and if there is much 
hypersemia or any inflammation of the conjunctiva, a mild astrin- 
gent collyrium, of zinc, acetate of lead, or alum should be pre- 
scribed. If there is much photophobia and lachrymation, together 
with phlyctenulse on the conjunctiva or cornea, atropine or bella- 
donna drops should be applied to the eye, and the compound 
belladonna ointment be rubbed in over the forehead. The general 
health should at the same time be attended to. 

In smallpox the eyes are apt to suffer in a far more dangerous 
manner, for the inflammation is not only more severe, but the 
variolous pustules may form on the lids, the conjunctiva, and even 
on the cornea, leading to grave, and often very dangerous com- 
plications. Happily, since the introduction of vaccination, the 
variolous ophthalmia is far less dangerous than formerly, when it 
led but too frequently to destruction of the sight. 

If a considerable number of pustules form on the eyelids, the 
swelling of the latter is often so great that it is impossible to open 
the eye. They are also apt to form at the very edge of the lid 
between the eyelashes, and often destroy the hair bulbs, thus pro- 
ducing perhaps permanent loss of the eyelashes (madarosis). If 
they are situated on the palpebral conjunctiva near the edge of the 
eyelid, they may obliterate the openings of the Meibomian glands, 
and cause a stoppage and alteration in their secretions; or the 
growth and arrangement of the lashes may become affected, and 
distichiasis or trichiasis be produced. If the pustules form on the 
limbus conjunctivae, they are chiefly dangerous inasmuch as they may 
extend to the cornea. The very prevalent opinion that variolous 
pustules often form on the conjunctiva and the cornea, during the 
eruptive stage, has been distinctly denied by Drs. Gregory and Mar- 
son. The latter especially maintains most strongly that no pustules 
form on the eye. The conjunctival inflammation met with in small- 
pox may assume the catarrhal, muco-purulent, or phlyctenular cha- 
racter. The latter is perhaps the most common. The eyelids and 
lachrymal apparatus are often affected, and this frequently gives rise 
to very obstinate and troublesome complications. But the eye may 
become implicated at a later stage of the disease, when the scales 
have fallen off from the pustules. Hence this has been termed by 
some writers, " secondary variolous ophthalmia." Mackenzie men- 
tions that he has often seen both central abscess of the cornea and 
onyx at its lower edge produced, after the general eruption has 
completely gone. Although this mostly occurs about the 12th day, 



90 DISEASES OF THE CONJUNCTIVA . 

he states that it may even take place five or six weeks after the 
patient has recovered from the primary disease. At first an infil- 
tration of the cornea occurs, which generally soon passes over into 
an ulcer, and this, increasing in circumference and depth, may per- 
forate the cornea, producing prolapse of the iris or partial staphy- 
loma. If several such infiltrations should coalesce, a large ulcer 
or abscess will be formed, giving rise to an extensive leucoma, 
even if the cornea do not perforate. Should the whole cornea be 
destroyed by suppuration, a complete staphyloma will be the result. 
Again, the inflammation may attack the other structures of the 
eye, and the latter be lost from panophthalmitis. 

The treatment should be much the same as that recommended for 
the ophthalmia of measles and scarlatina. In order to prevent the 
formation of pustules on the eyelids, glycerine, olive oil, or un- 
scented cold cream should be freely rubbed over them three or four 
times daily. Mackenzie recommends that two or three leeches 
should be applied to the temples, or behind the ears. In the sec- 
ondary variolous ophthalmia, he has found much benefit from 
tartar emetic, given so as to cause free vomiting and purging. 
The general health should be kept up by tonics, and the bowels 
properly attended to. If pustules form on the lids or conjunctiva, 
they should be pricked and emptied of their contents. If the 
cornea becomes implicated, and perforation is threatened, this 
must be treated according to the rules laid down in the treatment 
of ulcers of the cornea. 

In erysipelas of the face, the conjunctiva is often affected, and 
this is accompanied by very great swelling of the eyelids. The 
cornea becomes but seldom implicated. 



10.— XEROPHTHALMIA. 

In this condition, the conjunctiva is thickened, dry, and of a 
dusky red color, its epithelial surface being rough and scaly. If 
the affection exists to a considerable extent, both the palpebral 
and ocular conjunctiva assume a dirty, grayish-white appearance, 
and become rough, dry, and cuticular. This condition is due to 
atrophy of the conjunctiva, subconjunctival tissue, and even of the 
cartilage, all of which undergo cicatricial changes, the nature of 
which has been already mentioned under the head of granular 
ophthalmia. The secreting apparatus of the conjunctiva is more 
or less destroyed, and this membrane assumes more the character of 
the cutis. On account of this disturbance in the secretions of the 
eye, the latter appears dry, and the patient experiences a most 
annoying sensation of heat, dryness, and stiffness in the eyes, and 
the puncta are generally much contracted, or even obliterated. 
The semilunar fold is hardly apparent. There is, moreover, always 
more or less posterior symblepharon, so that the hollow in the 
retro-tarsal region is obliterated, and the palpebral conjunctiva 
passes abruptly on to the eyeball. Sometimes small frsena exist 



PTERYGIUM. 91 

between the lid and the globe. During the movements of the eye, 
the ocular conjunctiva is thrown into small concentric folds round 
the cornea. The latter is generally opaque, often very considerably 
so, the opacity assuming perhaps the character of pannus, and ex- 
tending over the greater portion, or even the whole, of the cornea. 
The surface of the cornea is generally rough and uneven, and its 
sensibility, as well as that of the conjunctiva, is greatly impaired, 
so that mechanical irritants, dust, dirt, foreign bodies, etc., are 
hardly felt, and excite little or no irritation. 

Xerophthalmia is generally caused by long-continued and severe 
inflammation of the conjunctiva, more especially by the chronic 
diffuse granular ophthalmia, which is so apt to give rise to exten- 
sive atrophy and cicatrices of the conjunctiva and tarsal cartilage. 
It may also arise after diphtheritic conjunctivitis, or be produced 
by injuries to the conjunctiva, from strong acids, lime, etc., and 
the excessive and long-continued use of strong caustics, more 
especially the nitrate of silver. In the latter case, we find not 
only that the palpebral and ocular conjunctiva have become dry 
and cuticular, but that they are very markedly discolored, being 
of a dirty, olive-green tint, which is extremely unsightly. 

Unhappily no treatment is of much avail. We can only en- 
deavor to remedy the dryness of the eye, due to the absence of its 
normal secretions, by the frequent use of some bland fluid em- 
ployed as a collyrium. I have found milk answer far better than 
any other, which has been also strongly recommended by Von 
Graefe. Benefit is also sometimes experienced from the use of 
glycerine, which was first proposed by Mr. Taylor. The effect of 
these applications is to soften and wash away the hardened epithe- 
lial scales, and sometimes perceptibly to clear the opacity of the 
cornea. 

11.— PTERYGIUM. 

This affection is due to an hypertrophy of the conjunctival and 
subconjunctival tissue, showing here and there tendinous or fibril- 
lar expansions. The elevated portion of the conjunctiva is 
traversed by numerous bloodvessels, which run a horizontal course. 
If the vascularity is but slight, and the hypertrophy of the tissue 
but inconsiderable, it is termed 'pterygium tenue [Fig. 20], where 
as, if the thickening is excessive and the development of blood- 
vessels great, so that it looks like a well-marked red elevation — 
somewhat resembling a muscle — it is called •pterygium crassum. 
[Fig. 21.] It is always triangular or fan-like in shape, having its 
base, which is often very wide, turned towards the semi-lunar or 
retro-tarsal fold, and its apex towards the cornea. It sometimes 
passes close up to the edge of the latter and stops short just at the 
limbus conjunctivae ; in other cases it passes beyond ihia, and ex- 
tends more or less on to the corner, even reaching, perhaps, to the 
centre, but very seldom extending beyond the latter. Its apex is 



92 



DISEASES OF THE CONJUNCTIVA. 



generally not very acute or pointed, but rather rounded oft* or 
indented. The portion situated on the cornea looks tendinous 




rather than vascular, or is made up of loose connective tissue like 
that on the sclerotic. It may be so superficial as to be readily 
shaved oft", or it may extend deeper into the substance of the 
cornea, so that when it is removed , an irregular hollow or furrow 
is left behind. The pterygium is mostly but loosely connected 
with the sclerotic and cornea, and with a pair of forceps it can 
readily be lifted up in a fold. But if the tendinous bands in its 
conjunctival portion are considerable and dense, this laxity is a 
good deal impaired and the elevation is rather tense and stretched, 
thus impeding the movements of the eyeball to a certain extent, 
which gives rise to a sensation of tightness or dragging when the 
eye is moved. The pterygium is most frequently met with at the 
inner angle of the eye, corresponding to the situation of the in- 
ternal rectus muscle. It is occasionally symmetrical in the two 
eyes. It is less frequently seen at the outer angle, and still less 
upwards or downwards. In some rare cases, two or even more 
have formed on the same eye. It occurs in adults, but is most 
frequently seen in persons beyond middle age, and very rarely in 
children. 

The causes of pterygium are often somewhat obscure and un- 
certain, as its formation is generally very slow and gradual. There 
can be no doubt that long and constant exposure to heat, glare, 
wind, dust, and chemical irritants may produce it, by setting up a 
state of chronic irritation of the conjunctiva, which gradually leads 
to a thickening and hypertrophy of this membrane and of the sub- 
conjunctival tissue. This occurs particularly in situations which 
are specially exposed to these influences, namely, at the inner and 
outer angle of the cornea, which lie in the palpebral aperture, and 
are unprotected by the lids. I have frequently met with this 
affection in persons who have long resided in hot climates, espe- 
cially in several natives of the "West Indies, and this a°rees with 



PTERYGIUM. 93 

the experience of other observers. Pterygium may also be pro- 
duced by phlyctenular and even catarrhal ophthalmia. 

Arlt 1 has, I. think, offered by far the most reasonable and prob- 
able explanation of the formation of pterygium in many cases. He 
thinks that it is frequently produced in the following manner : 
If a superficial ulcer or abrasion (due perhaps to some chemical or 
mechanical injury) exists at the very edge of the cornea, the con- 
junctiva near it, particularly if it be somewhat excoriated and 
relaxed, as is often the case in old people, falls against it, and be- 
comes adherent to the ulcer, being at the same time dragged some- 
what towards it. This is always accompanied by a certain degree 
of irritation and serous infiltration of the conjunctiva, which, on 
the serum becoming absorbed, causes a certain amount of contrac- 
tion and dragging of the membrane. Should the external irritants 
continue to act upon the eye, we can easily understand how this 
condition is not only maintained but increased in extent, the con- 
junctiva being gradually more and more dragged upon and in- 
volved in the process. Hasner 2 has more lately pointed out that 
the connection between the conjunctiva and subconjunctival tissue 
at the limbus conjunctivae is often relaxed, more especially in aged 
persons, and that this forms a frequent predisposing cause of ptery- 
gium. A simple hypertrophy of the tissue may then suffice to 
draw up the neighboring conjunctiva, but this will, of course, be 
much more likely to occur if an ulcer or excoriation is formed, for 
during the cicatrization the conjunctiva will be more or less dragged 
upon. The pterygium is often but of slight extent and may in- 
crease but very slowly, remaining indeed almost stationary for a 
length of time, and without perhaps encroaching upon the cornea. 
In other cases its course is more rapid, and it may extend quite to 
the centre of the cornea, thus more or less affecting the sight and 
impairing the movements of the eye. Even if the pterygium is in 
such cases removed, some opacity of the cornea will remain, so that 
it may be necessary to make an artificial pupil. 

If the pterygium is bat small, and is chiefly confined to the scle- 
rotic, benefit is often derived from the application of astringent 
collyria, such as the sulphate of copper or zinc, the vinum opii, or 
even the nitrate of silver, more especially if there is any catarrhal 
ophthalmia. The application of the powdered acetate of lead (as 
recommended in granular ophthalmia) has also been advocated 
(Deconde). But if the disease is considerable, so that it annoys the 
patient during the movements of the eye, or if from its position on 
the cornea the sight is affected, these remedies will not suffice, and 
we must have recourse to operative treatment. Unfortunately this 
is not always so successful as we could desire, for, if the pterygium 
encroaches much on the cornea, an extensive opacity will be left ; 
and if the base of the pterygium is large the loss of substance will 
be considerable, and the resulting cicatrix will be dense, tendinous, 

1 " Diseases of the Eye," 1855, 1, p. 160. 

2 "Clinical Observations," Prague, 18(55. 



94 DISEASES OF THE CONJUNCTIVA. 

and more or less prominent, giving rise to what has been termed 
" secondary pterygium," which may even necessitate a further ope- 
ration. This is especially apt to occur if excision has been per- 
formed, and the wound has been made triangular in shape. 

Numerous modes of operating for pterygium have been advocated, 
but I shall confine myself to the description of the three following, 
viz.: 1. Excision; 2. Transplantation; 3. Ligature. Of these I 
have found the transplantation the most successful. 

1. Excision. — This operation is to be performed in the following 
manner: The patient having been placed under the influence of 
chloroform, and, the eyelids kept apart by the spring speculum, the 
operator seizes the pterygium with a pair of finely-toothed forceps 
and, raising it up, carefully abscises the corneal portion either with 
a cataract knife or a pair of curved scissors. "When the pterygium 
has been removed from the cornea, its conjunctival portion is to be 
excised up to about 1 \ or 2 lines from the edge of the cornea. The 
lines of incision should run along the upper and lower edge of the 
pterygium for the desired extent, and should then be made to 
converge towards each other, so that the wound may not assume a 
triangular but a rhomboidal shape. The hypertrophied tissue 
having been thoroughly removed, the edges of the conjunctival 
wound are to be accurately brought together by two or three fine 
sutures. As the edges of the incision are apt to be somewhat 
uneven and ragged from the irregular dragging of the conjunctiva 
into the pterygium, I have found it advantageous to pass the threads 
through the conjunctiva prior to the excision, so as to embrace the 
pterygium to the desired extent, and then to make the incisions 
within the lines of the sutures, which will be a guide to the ope- 
rator and enable him to render them more straight and even. The 
suggestion of making the wound rhomboidal, instead of triangular, 
is due to Arlt. The chief advantage of this is, that its edges can 
thus be made to fit more neatly and closely together, that it yields 
a more even and straighter line of adhesion, and that the tendency 
to the formation of a thick, prominent cicatrix is thus greatly 
diminished ; whereas, if the wound is made triangular, the angles 
of the base of the triangle become puckered and projecting when 
the edges are united by sutures, and' the central portion of the base 
is apt to be drawn towards the cornea, thus increasing the tendency 
to a prominent cicatrix. 

It is not necessary, nor indeed desirable to remove the pterygium 
as far as the semilunar or retro-tarsal fold, for the extent men- 
tioned above will generally suffice. Pagenstecher 1 does not excise 
the pterygium, but, having separated it from the cornea and the 
sclerotic to the required extent-, he simply turns it back, and bring3 
the edges of the wound together by sutures. The pterygium soon 
shrinks, dwindles down, and gradually disappears altogether. 

2. Transplantation, which is chiefly applicable when the pte- 
rygium is very large, was first introduced by Desmarres. 2 He 

1 "Klinische Beobachtungen," 1861, 15. * "Maladies des Yeux," 2, 169. 



PTERYGIUM. 



93 



abscises the pterygium from the cornea and sclerotic quite up to 
the base, and then turns it back towards the nose. He next makes 
an incision in the conjunctiva near and parallel to the lower edge 
of the cornea, and sufficiently large to receive the pterygium ; the 
latter is then inserted into the incision and retained in this position 
by a few sutures. The chief advantages of this proceeding are, 
that the conjunctiva is preserved, that the pterygium soon shrinks 
in its new situation, and that there is far less chance of recurrence 
than when excision is practised. To avoid the prominence pro- 
duced by the transplantation of a large pterygium, Bhapp 1 practises 
the following modification of Desmarres' operation : Having dis- 
sected off the corneal portion of the pterygium, he makes two 
curved incisions running from the upper and lower borders of the 
base of the pterygium towards the corresponding retro-tarsal fold. 
He then excises the corneal part of the pterygium, and with a pair 
of straight scissors divides the remaining portion by a horizontal 
incision. Next, a small square flap of conjunctiva is to be dissected 
oft" from the subjacent tissue above and below the wound, so as to 
cover the latter. The contraction produced by this causes the 
curved incisions to gape sufficiently to receive the horizontal 
halves of the pterygium, which are to be fastened in these incisions 
by sutures. The line of junction of the conjunctival flaps is also 
to be united by a couple of sutures. 

3. The ingenious operation by ligature was suggested by Szo- 
kalski. 2 A couple of small curved needles having been armed with 
the ends of a fine silk thread, the operator, lifting up the pterygium 
with a pair of forceps, inserts one needle at its upper edge, near the 
cornea, and passing it beneath 
the pterygium, brings it out at 
the lower edge. (Fig. 22.) The 
other needle is then passed in 
the same manner beneath the 
pterygium, near its base. The 
needles are next cut off, and the 
ligature will consequently be di- 
vided into three portions, viz., 
an outer, an inner, and a cen- 
tral one. The ends of the inner 
thread are then to be firmly 
tied, so as to tightly embrace 
this portion of the pterygium, 
then the ends of the outer thread 
are to be united, and finally, the 
two ends of the central ligature, 
which lie at the lower edge of 
the pterygium, are to be firmly 
tied. The ends of the ligatures 



Fig. 22. 




After Stellwag von Cariou. 



1 "A. f. O.," 14, 1, 2fi7. 

2 "Arch. f. Physiol-Heilkunde," 1845, 2. 



9b DISEASES OF THE CONJUNCTIVA. 

may be snipped off", or fastened to the cheek by strips of adhesive 
plaster. At the end of four days, the strangulated portion of the 
pterygium may generally be easily removed with a pair of forceps. 
The affection is said never to recur after this operation. 

"We must not confound a little yellow spot near the cornea 
(Pinguecula or pterygium pingue) with true pterygium. It often 
appears on the conjunctiva of elderly persons, near the edge of the 
cornea, in the form of a small yellow elevation. It is not of a 
fatty nature, but is due to an hypertrophy of the subconjunctival 
tissue, accompanied by thickening of the epithelium. It but 
seldom causes anj' inconvenience ; should it do so, it may be 
snipped oft" with a pair of scissors. 



12— SYMBLEPHARON. 

In this affection there exists an adhesion between the conjunctiva 
of the eyelid and that of the eyeball. This frsenum may be exten- 
sive, and nearly the whole length of the palpebral conjunctiva (of 
one or both lids) be adherent to the opposite surface of the globe, 
producing a considerable limitation of the movements of the eye- 
ball ; or, the adhesion may be very limited, so that only a narrow 
bridle exists. In the latter case, there may be simply a small 
bridge of conjunctiva passing from the lid to the eyeball, readily 
permitting the passage of a probe beneath it; or, the adhesion 
may include a portion of the retro-tarsal fold, in which ease no 
passage would exist. In some cases, we have a combination of the 

two, the probe passing only part of 

[Fig. 23. the way. If the palpebral conjunctiva 

adheres to the cornea, it has been 

jg§§§| termed " symblepharon cum corned" 

[Fig- 23], and it then assumes some- 
'J*t» F^fer what the character and appearance of 

V^^ ' ~ a pterygium. The most frequent 

i causes of symblepharon are injuries 

from red hot metal, molten lead, 
^ %^MS| strong acids, or quicklime, or from 

' gunpowder exploding near the eyes. 

ff' These produce more or less extensive 

/ sloughing and excoriation of the con- 

After Mackenzie] junctiva of the lid and eyeball, granu- 

lations form, and the opposite ex- 
coriated surfaces become firmly united. If these adhesions are 
but of limited extent, the constant movements of the eyeball will 
gradually stretch them, until the frsena become perhaps considerably 
elongated. "Wounds penetrating through the eyelids into the globe 
may also produce symblepharon. It is but seldom due to ulcera- 
tions or pustules accompanying non-traumatic inflammation of the 
conjunctiva. 
The effect which an operation will have in the cure of a sym- 



SYMBLEPHARON. 97 

blepharon will depend chiefly upon the extent of the latter. If it 
is very considerable, embracing the retro-tarsal fold, and producing 
a close adhesion between the lid and the eyeball, but little good 
can generally be done by an operation. The most favorable cases 
are those in which a narrow band passes like a bridge from the 
palpebral to the ocular conjunctiva, so that a probe can be freely 
inserted beneath it. But even those cases in which the adhesion 
passes to the retro-tarsal fold may sometimes be much improved 
if the frsenum is but small. If one or two narrow membranous 
bands exist, they should be put on the stretch and divided close to 
the globe, and reunion should, if possible, be prevented by fre- 
quently passing a probe, dipped in a little oil or glycerine, between 
the raw surfaces ; or, these may be touched lightly with a crayon 
of nitrate of silver, in order that an eschar mny be formed, and 
adhesion prevented. 

When the adhesion is more extensive, a simple division of the 
frsenum will not suffice, for the raw surfaces will be so considera- 
ble in size, that they are sure to reunite, for, as they contract 
during granulation, the opposing surfaces will be again drawn 
towards each other. Many of these cases appear to do very well at 
first, but, after a time, a relapse generally occurs, so that finally 
they are hardly, if at all, improved by the operation. In order to 
prevent this reunion of the raw surfaces, it has long been proposed 
to interpose a small shield of glass, horn, or ivory between the lid 
and eyeball. This has often been tried, but has almost always 
failed, except where the frsena are very narrow, for as the wound 
cicatrizes, the parts in its vicinity contract, and thus gradually 
push out the shield. Mr. "Wordsworth 1 uses a glass mask, instead 
of a metal shield. It is a glass shell, like an artificial eye, having 
a central aperture for the cornea. He has found it very successful 
in the treatment of extensive frsena, and in cases of destruction of 
the epithelium of the conjunctiva, in which symblepharon was 
imminent. 

In order to obviate this tendency to reunion, Arlt has introduced 
and practised with success the following operation. 2 The eyelid 
having been drawn away from the globe, so as to put the frsenum 
well on the stretch, the operator passes a curved needle, armed with 
a fine silk thread, through the symblepharon, close to the cornea r 
the adhesion is then to be carefully dissected off from the cornea 
and sclerotic as far as the retro-tarsal fold. Two curved needles 
having been armed with the thread, the symblepharon is doubled 
down, so as to bring its conjunctival surface in contact with the 
raw surface of the globe, and the needles are then passed through 
the thickness of the lid, close to the orbital edge, and the sutures 
tied on the outside of the lid, so as to keep the symblepharon folded 
down in the required position. If the frsenum is not very broad,, 
the edges of the wound in the ocular conjunctiva should be brought 
together by two or three fine sutures. After the operation, cold 

1 "li. L. O. H. Rep.," 3, 216. * "Prager VierteljalirscUrift, xi. 161. 

7 



DISEASES OF THE CONJUNCTIVA. 



compresses are to be applied. When the conjunctival wound is 
healed, the turned down symblepharon, which will by this time 
have shrunk considerably, may be excised if it should prove irksome 
to the patient. 

The operation which I have found most successful for the perma- 
nent cure of moderate cases of symblepharon, is that of transplan- 
tation, for which we are indebted to Mr. Teale. 1 He describes the 
mode of operating, as follows : — 

" Having first made an incision through the adherent lid, in a 
line corresponding to the margin of the concealed cornea (see A, 
Fig. 24), I dissected the lid from the eyeball, until the globe moved 
as freely as if there had been no unnatural adhesions. Thus, the 
apex of the symblepharon (A, Fig. 25) being part of the skin of 
the lid, was left adherent to the cornea. 





Fie 


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Fig. 


25. 


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fci&! V; ' 


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te 


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''^*m» 


7vK 




dp--"' '"'' v 


Nil 


^2j$0 




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3^\v 



" In the next place, two flaps of conjunctiva were formed, one 
from the surface of the globe, near the inner extremity of the raw 
surface, the other from the surface of the globe, near the outer 
extremity. I first marked out, with a Beer's knife, a flap of con- 
junctiva (B, Fig. 25), nearly a quarter of an inch in breadth, and 
two-thirds of an inch in length, with its base at the sound con- 
junctiva, bounding the inner extremity of the exposed raw surface, 
and its apex passing towards the upper surface of the eyeball. The 
flap was then carefully dissected from the globe, until it was so far 
at liberty as to stretch across the chasm without great tension, care 
being taken to leave a sufficient thickness of tissue near its base. 
A second flap was then made on the outside of the eyeball in the 
same manner. In making the flaps, conjunctiva alone was taken, 

the subconjunctival tissue not being in- 

Fig. 26. eluded. The two flaps thus made were 

.^sssa&M&wy t ^. en adjusted in their new situation (see 

x^^t^ Fig, 26). The inner flap, B, was made 

/JfV^fikv >§h t0 8tretcl1 across the raw surface of the 
' ' ; eyelid, being fixed by its apex to the 

healthy conjunctiva, at the outer edge of 
the wound. The outer flap, C, was fixed 
across the raw surface of the eyeball, its 
apex being stitched to the conjunctiva 

R. L. 0. H. Rep.," 3, 253. 




ANOHYLOBLEPHARON. 99 

near the base of the inner flap. Thus, the two flaps were dove-tailed 
into the wound. The flaps having been adjusted in their new posi- 
tion, their vitality was further provided for by incising the conjunc- 
tiva near their base, in any direction in which there seemed to be 
undue tension, and by stitching together the margins of the gap 
whence the transplanted conjunctiva had been taken (e. g. D, E, 
Fig. 26). One or two other sutures were inserted, with a view to 
prevent doubling in of the edges of the transplanted conjunctiva." 
The apex of skin left on the cornea soon atrophies and disappears. 



13.— ANCHYLOBLEPHARON. 

Ey this is meant a more or less extensive, thin, membranous or 
cicatricial adhesion of the edges of the eyelids to each other. It 
frequently coexists with symblepharon, the same injury having 
given rise to both these conditions. Sometimes, the adhesion is 
confined to the inner angle of the eye, leaving perhaps a small 
opening through which the 
tears can escape and a probe IJ ' 

may be passed. [Fig. 27.] Ex- 
tensive membranous adhesions 
between the edges of the lid are 
generally congenital. The most 
frequent causes of ankyloble- 
pharon are chemical and me- __ = s== 
chanical injuries, such as burns 
or scalds from hot iron, molten After Won.] 

lead, strong acids, etc. In these 

cases there is generally also symblepharon. Blepharitis, accom- 
panied by ulcerations at the edge of the lids, may produce it, if the 
ulcers are situated opposite to each other on the two lids, and kept 
for a long time in contact by the eye being bandaged (Stellwag). 

Before an operation is attempted for the cure of ankyloble- 
pharon, the surgeon should ascertain whether or not symblepharon 
coexists, and if so, what is its extent, and whether it involves the 
cornea or not. For if the lid be widely adherent to the cornea, 
little or no benefit will accrue from an operation. If a small opening 
exists at the nasal side, or if the ankyloblepharon is but partial, a 
probe should be passed in underneath the lid, so as to ascertain 
whether any adhesions exist between it and the eyeball. If the 
adhesion between the eyelids is complete, the best way of deter- 
mining this is to pinch the upper eyelid into a fold so as to draw 
it away from the globe, and then to order the patient to move his 
eye in different directions, when we can easily estimate the freedom 
of the movements. We should also examine what perception of 
light the patient still enjoys, in order, if possible, to ascertain 
whether the cornea and retina are healthy or not. 

If the adhesion between the eyelids is not very considerable, con- 
sisting perhaps of one or more small bands, it should be simply 




100 DISEASES OF THE CONJUNCTIVA. 

divided close to the edge of the lid. In order to prevent readhe- 
sion of the surfaces, these should be touched with collodion 
(Haynes "Walton). If the ankyloblepharon is complete, but a small 
opening exists near the nasal portion, a grooved director should be 
passed in through this, and run behind the adhesion, which is to 
be divided uponlt with a scalpel. If no opening exists, the operator 
should at one point lift up the lids from the eyeball in a vertical 
fold, and divide the adhesion here, then introduce a director through 
this incision, and finish the operation with its aid. 



14.— INJURIES OF THE CONJUNCTIVA.' 

These may be of a mechanical or chemical nature. The former 
may prove injurious by their contact with the conjunctiva, setting 
up irritation and inflammation, or from their wounding and lacer- 
ating this membrane. The foreign bodies most frequently met with 
on the conjunctiva are bits of steel, iron, glass, coal, straw, dust, 
etc., which may remain lodged on its surface, or become more or 
less deeply imbedded in its structure. The presence of a foreign 
body in the eye generally sets up at once severe symptoms of ciliary 
irritation. The eyelids are spasmodically contracted, the ocular 
conjunctiva becomes injected, and a bright rosy zone appears round 
the cornea; there is also much photophobia, lachrymation, and a 
feeling as of sand and grit in the eye or under the upper lid. 
Sometimes, the pain and ciliary neuralgia are considerable, and the 
pupil is markedly contracted. If the foreign body is small, and 
simply lies on the conjunctiva, the movements of the eyelids, the 
rubbing of the eye by the patient, and the copious lachrymation 
will often suffice to extrude it. If the surgeon suspects the presence 
of a foreign body, he must carefully and closely examine the sur- 
face of the palpebral conjunctiva of both lids, as well as the ocular 
conjunctiva and the cornea. The lower eyelid is to be depressed 
by the fore and middle finger so as to bring its inner surface, and 
especially the retro-tarsal fold, well into view, the patient at the 
same time being directed to look upwards. 

The upper lid is next to be well everted, and its lining mem- 
brane thoroughly scanned, more particularly the retro-tarsal region, 
within the folds of which the foreign body often lies hidden, and 
may easily escape detection. Cases are narrated in which an un- 
discovered foreign body has set up a severe and obstinate ophthal- 
mia. When found, the foreign body should be removed with the 
spud [Fig. 28], which should be inserted beneath it, and gently lift 
it out. If it has got somewhat imbedded in the conjunctiva, Mr. 
Haynes "Walton's gouge [Fig. 29] will be found very serviceable. 
If the foreign bodies, more especially shot or small splinters of glass 
or steel, etc., are buried in the conjunctiva, their exact situation 
should be ascertained by lightly passing the finger over the surface 
of the conjunctiva, and they should then be excised with perhaps a 
small portion of the latter. Sometimes, impalpable bits of dust or dirt 



INJURIES OF THE CONJUNCTIVA. 



101 



[Fig. 28. Pig. 29.] 



get upon the conjunctiva, and set up a good deal 
of irritation. The lids being well everted, a blunt 
probe should be passed over their lining mem- 
brane and behind the retro-tarsal fold, which will 
sweep oft' any such portions. The surface of the 
conjunctiva should then be washed by a stream 
of lukewarm water, directed upon it from a 
sponge or a syringe. If sand or grit has got into 
the eye, it should also be washed away in this 
manner. After the removal of a foreign body 
a little castor or olive-oil should be dropped into 
the eye, and if there has been great irritation, 
cold compresses should be applied to the lids. 

Chemical injuries may produce a more or less ex- 
tensive abrasion of the epithelium, or excoriation 
of the surface of the conjunctiva ; if the injury was 
severe or the chemical agent very strong, a deep 
slough of this membrane may occur, which, in cicatrizing, will 
cause a considerable contraction of the neighboring tissues. Plastic 
lymph is effused, and the opposite, raw surfaces of the conjunctiva 
become closely adherent, hence these injuries so frequently give 
rise to symblepharon and anchyloblepharon. Sometimes, deep 
and obstinate ulcers are formed, the surface of which becomes 
covered with sprouting granulations. 

Injuries from lime are unfortunately of common occurrence, and 
are very dangerous in their nature, for this agent is strongly irri- 
tant, producing not only destruction of the epithelium and the sur- 
face of the conjunctiva, but more or less deep and extensive sloughs 
of this membrane and of the cornea. It, therefore, frequently de- 
stroys the sight, or in more favorable cases gives rise to an exten- 
sive symblepharon. If the patient is seen at once, a weak solution 
of vinegar and water (3j, to §j of water), or of dilute acetic acid 
should be very freely injected under the lids; this will produce an 
innocuous acetate of lime. Then a few drops of olive or castor-oil 
should be applied to the eye, so as to lubricate the surface of the 
conjunctiva, and the surgeon, everting both lids, should proceed to 
remove every particle of lime. This having been done, the eye 
should be well washed by letting a stream of lukewarm water 
from a sponge or syringe play upon the surface of the conjunctiva. 
A few drops of olive-oil should be applied three or four times a day. 
The eschars which form on the conjunctiva must be removed with 
a pair of forceps. If there is much conjunctivitis with a muco- 
purulent discharge, mild astringent collyria of sulphate of zinc or 
nitrate of silver must be employed, or the eye may be frequently 
washed with a glycerine lotion (Glycerin 3J ad Aq. dest, 3vij) a 
little being allowed to flow into the eye. But when the sloughs 
are detached, astringents should not be used, as they will excite too 
much irritation. Nor should they be used if the eye is very irri- 
table and painful, or the cornea is affected. In such cases soothing 
applications are indicated, such as the belladonna-lotion, compound 



102 DISEASES OF THE CONJUNCTIVA. 

belladonna-ointment rubbed on the forehead, poppy fomentations, 
etc. 

Sirong acids, such as the sulphuric or nitric, produce extensive 
sloughing of the conjunctiva and cornea, accompanied by severe 
symptoms of irritation. Generally, however, the eyelids suffer the 
most, and the deep sloughs which may be produced frequently give 
rise to entropion. 

After an injury from strong acids, the eye should be syringed out 
with a weak solution of carbonate of soda or potass (9j to 3iv — vj 
Aq. destill.), in order to neutralize the acid. Afterwards olive-oil 
is to be dropped in. 



J 5.— TUMORS OF THE CONJUNCTIVA, ETC. 

Polypi are occasionally met with in the conjunctiva, especially at 
the semilunar fold or caruncle. They appear in the form of small 
pink lobulated elevations or excrescences, and have a distinct 
pedicle. Although they are generally small, they may reach the 
size of a hazel-nut, 1 and protrude between the aperture of the lids. 
They may be readily snipped off with a pair of curved scissors, or a 
scalpel, but are apt to bleed rather freely. The hemorrhage may, 
however, be easily arrested by a light touch with a crayon of nitrate 
of silver, which will, moreover, check the tendency to a recurrence 
of x the disease. 

Pinguecula might be mistaken by a superficial observer for a 
slightly developed pterygium, as it is a small triangular elevation, 
situated generally close to the edge of the cornea, towards which 
its base is turned. It occurs at the outer or inner edge of the 
cornea, and is due to an hypertrophy of the conjunctival and sub- 
conjunctival tissue, as well as of the epithelial cells, but it does not 
contain any fat, as might have been suspected from its yellow tint. 
It is chiefly met with in old persons, and is due to a chronic irrita- 
tion of the conjunctiva. It generally remains small and station- 
ary, and produces no particular inconvenience or disfigurement. 
Should it, however, increase in size, or its appearance prove dis- 
agreeable to the patient, it may easily be excised. 

Fatty tumors are of rare occurrence, and are most frequently 
observed on the ocular conj unctiva at some little distance from the 
cornea, and between the recti muscles, more especially the superior 
and external rectus, in the vicinity of the lachrymal gland. They 
are often due to an hypertrophy and extension of the adipose tissue 
of the orbit. They appear in the form of smooth, yellow, lobulated, 
elastic tumors, and may reach a considerable size. They are mostly 
congenital, and do not become very noticeable or increase greatly 
in size until a much later period. When they attain considerable 
proportions, they may push the eyeball aside, and by pressure 
impede the functions of the lachrymal gland. 

1 Graefe, "A. f. 0.," i. 1, 289. 




TUMORS OF THE CONJUNCTIVA. 103 

If the tumor is inconsiderable in size, it may be easily removed, 
but care should be taken to preserve the conjunctiva as much as 
possible, and the incision should be closed by a fine suture. 

Dermoid tumors are not of unfrequent occurrence. They are 
situated at the limbus conjunctivae, partly on the cornea, and partly 
on the sclerotic [Fig. 30], are of a pale, 
whitish-yellow color, about one or two [Fig. so.] 

lines in diameter, and somewhat raised 
above the level of the cornea. The surface 
of the tumor is generallv smooth, but it 
may be lobulated, and from it one or two 
short hairs may protrude. Wardrop 1 men- 
tions an extraordinary case in which twelve 
very long hairs grew from the middle of * 
the tumor, passed through between the 
eyelids, and hung over the cheeks ; these 
hairs had not appeared till the patient was 
16 years of age, at which time his beard 
also began to grow. The tumor is generally congenital, and almost 
completely stationary, increasing very slowly in size with the 
growth of the body. It may, however, become developed later in 
life, and augment considerably in size. The largest tumor of the 
kind that I have met with I saw in Von Graefe's clinique, in 1860. 
It extended over the outer two-thirds of the cornea, was prominent, 
lobulated, and very disfiguring, almost hiding the cornea. From 
their close analogy to the structure of the skin, these tumors have 
been called " dermoid." They sometimes, however, appear to con- 
sist only of elastic fibrillar connective tissue, rudiments of true skin, 
fat, hairs, and sebaceous follicles. Marked increase in their size, or 
recurrence after removal, appears to be due to an increase in their 
fatty constituents. They may be readily excised, but care must be 
taken not to endeavor to remove them thoroughly from the cornea, 
as they sometimes extend deeply into its structure. 2 

[Dr. Taliaferro, of Kentucky, has recorded 3 an interesting case of 
a female aged 15, who had a congenital dermoid tumor on each eye. 
The tumors were of a delicate pink color at their base, becoming 
brownish at their apices. The tumor on the left eye, Fig. 32, at 
its base measured five lines in one diameter, by three and a half 
in the other, and rose in a conoidal form to about six lines in height. 
It almost covered the lower two-thirds of the pupil. From the 
apex grew some ten or twelve hairs, about sixteen lines in length, 
and a shade darker than the cilia. The tumor of the right eye, 
Fig. 31, was in shape and position similar to the one on the left, 
but of about half the size, and covering only the lower sixth of 
the pupil. The tumors were excised with excellent results.] 

Warts are occasionally seen on the conjunctiva, forming small, 

1 Wardrop's "Morbid Anatomy of the Human Eye," 1, 32. 

2 Vide Graefe's articles "On Dermoid Tumors," A. f. O., vii. 2, and xii. 2, 227. 

3 "American Journal of Medical Sciences," 1841, N. S., II., 88. 



104 



DISEASES OF THE CONJUNCTIVA. 



red, flesh-colored excrescences, being met with either singly, or in 
little clusters. They may' occur on the palpebral or ocular conjunc- 
tiva, and also on the semi-lunar fold, and bear a strong resemblance 
to the warts upon the prepuce. They are generally accompanied 




by a certain degree of conjunctivitis, and a thin mucopurulent 
discharge. They should be at once snipped off with scissors before 
they attain any size, or have time to spread, and if necessary, the 
cut portion should be lightly touched with nitrate of silver. 

Cysts of the conjunctiva may be readily distinguished by their 
circumscribed round form, and their pink, translucent appearance, 
the transparency of their contents being easily recognized with the 
oblique illumination. They may occur in different portions of the 
conjunctiva, and vary in size from a small pea to that of a hazel- 
nut, or they may even exceed this. If they extend into the orbit, 
and attain a considerable size, they cause more or less protrusion 
of the eyeball. The walls of the smaller cysts are generally very 
thin, and only so slightly connected with the conjunctiva that they 
may be very readily removed. 

Cystieerci have been found several times beneath the ocular con- 
junctiva, and in one instance (Sichel) beneath the palpebral. There ^ 
is seen at some part of the ocular conjunctiva, near the angle of 
the eye, a transparent, cyst-like elevation, which is round, sharply 
defined, and somewhat movable, and varies in size from a pea to 
a small bean. The conjunctiva over the cyst, and in its vicinity, 
is somewhat hypersemic, but if it is sufficiently thin and transpa- 
rent, we may be able to distinguish at the outer wall of the cyst a 
peculiar yellow or grayish-white spot, which is the head and neck 
of the entozoon, and Sichel 1 states that this appearance is quite 
characteristic. 

Cancekous Tumors are sometimes met with as primary affections, 
but far more frequently as secondary diseases, after cancer of the 
lids or of the eyeball. 

' " Iconographie Ophthalraologique," p. 702. 



TUMORS OF THE CONJUNCTIVA. 103 

Epithelial cancer does not occur as a primary disease in the con- 
junctiva, but generally extends from the eyelids. It appears as a 
small, smooth, or slightly nodulated excrescence or button, at the 
edge of the cornea, and often bears a very striking resemblance to a 
pustule or phlyctenula. It may, however, be distinguished from the 
latter, by the absence of all inflammatory chemosis and irritation, 
and arterial injection, only a few dilated tortuous veins converging 
toward the little tumor, there is often also some serous infiltration. 
Subsequently the tumor increases in size, and assumes a redder tint, 
and its surface becomes more nodulated (cauliflower excrescences), 
being covered by dry, thickened epithelium ; or there may be a 
breach of surface, and a thin, muco-purulent discharge exudes from 
the ulcer. The tumor may invade the cornea to a considerable 
extent, but is generally but slightly adherent to it, so that it may 
be nearly entirely removed. It may, however, produce a dense 
opacity of the cornea beyond the limits of the tumor, or lead to 
deep and extensive ulceration, or even perforation. If the tumor 
is stalked, it may be freely movable upon the surface of the cornea. 
Like all cancerous growths, it should be removed at the earliest 
possible period, and the edges of the conjunctival wound should be 
closed with fine sutures, in order that the sclerotic may not be 
exposed. It is, however, very apt quickly to recur, when the 
operation should be repeated without loss of time. But if the 
tumor has invaded the cornea to a considerable extent, is inti- 
mately connected with its tissue, and has greatly impaired the 
sight, it will be better to excise the eye ; but even this does not 
always guard against recurrence, the new growth springing from 
the lids, or from the bottom of the orbit. In such cases it is, there- 
fore, always advisable to apply the chloride of zinc paste to the 
orbit, after the removal of the lids. 

Medullary cancer almost always extends to the conjunctiva from 
the lids or from the eyeball itself, the cornea or sclerotic giving 
way, and the tumor sprouting forth and very rapidly spreading 
thence into the neighboring tissues. 

Melanotic cancer appears in the form of a small darkish-red or 
brownish-black spot or tumor in the subconjunctival tissue near 
the cornea, at the semilunar fold or caruncle. As it increases in 
size, it may implicate the lids, extending beneath them and giving 
rise to more or less considerable adhesions. The tumor may remain 
stationary for a long period and then rapidly increase, and it is 
very prone quickly to recur after removal. It must be, however, 
remembered that many of the little black tumors which are often 
erroneously called melanotic cancer are only sarcomata. 

Syphilitic ulcers 1 are sometimes met with on the conjunctiva, 
being almost always situated at the edge of the lid, and they bear 
a strong resemblance to a chancre upon the prepuce ; in very rare 
instances they may occur at the edge of the cornea. 2 "We shall 

1 "British Med. Journal," March 18, 1865. 2 Wecker, i. 177. 



106 DISEASES OF THE CONJUNCTIVA. 

enter more fully into their description when speaking of the syphi- 
litic ulcers of the eyelids. 

Ncevi sometimes extend from the external portion of the eyelid 
to the palpebral or even ocular conjunctiva, and may reach a very 
considerable size if they are not treated at an early period. They 
may, however, occur primarily on the conjunctiva or the semilunar 
fold, and should be removed as early as possible. 

Lithiasis is a term applied to a hardening or calcification of the 
secretion of the conjunctival glands, more especially the Meibomian 
glands. The affection appears in the form of white, round concre- 
tions of the size of a pin's head, which may, however, attain larger 
dimensions on the inner surface of the conjunctiva. They occur 
either singly, being scattered about over the surface of the lid, or 
they may appear arranged in single file along the tract of the ducts 
leading from the gland. The latter is, however, much more rare. 
On account of the roughness which they produce on the lid, con- 
siderable irritation and even a certain degree of conjunctivitis may 
be set up. The little calculi are easily removed by incising the 
conjunctiva over them, and lifting them out with the point of a 
cataract needle, or a grooved spatula. Sometimes the concretion 
is soft and semi-transparent, and appears at the opening of the duct, 
whence it may be readily pressed out. 

The secretions of the caruncle also sometimes undergo eretifica- 
tion ; and chalky deposits are likewise met with in the caruncle, 
often giving rise to irritation and swelling. 

Pemphigus of the conjunctiva is a very rare affection, of which, I 
believe, only two cases have been recorded, viz., one by White 
Cooper, 1 the other by Wecker. 2 The symptoms are very charac- 
teristic, for one or more large vesicles form in the palpebral and 
perhaps also on the occular conjunctiva ; they contain a turbid 
serum and look exactly as if they had been caused by a burn or 
scald. There is generally a good deal of conjunctivitis, accompa- 
nied by lachrymation, photophobia, and perhaps some muco-puru- 
lent discharge. On bursting, the vesicle leaves a raw excoriated 
surface, which secretes a thick muco-purulent discharge. If re- 
peated crops of vesicles have appeared, they may gradually give 
rise to symblepharon. The treatment should consist of mild astrin- 
gent collyria, and the frequent application of glycerine to moisten 
the lids (Wecker). Internally, arsenic should be administered, for 
these patients always suffer from pemphigus of some other part of 
the body. 

Hemorrhage into the conjunctiva is generally produced by blows or 
falls upon the eye or face, or by severe straining as in coughing, 
sneezing, etc., causing a rupture of some of the minute bloodvessels 
of the conjunctiva. Such ecchymoses are also often met with in 
the course of inflammations of the conjunctiva, or in persons suf- 
fering from scurvy. In other cases, they occur spontaneously 
without any apparent cause ; I have met with several instances of 

1 "R. L. O. H. Rep," 1, 155. * " Kl. Mcmatsbl.," 1868, 232. 



TUMORS OF THE CONJUNCTIVA. 107 

this kind in which the ecchymosis had come on during the night. 
But the effusion of blood may not be due to a rupture of any of 
the conjunctival bloodvessels, but have gradually made its way 
forwards from the orbit beneath the conjunctiva. Thus a blow 
upon the skull may, by a contre-coup, produce a fracture of some 
portion of the walls of the orbit, this is followed by more or less 
severe hemorrhage, and the effused blood may make its way for- 
wards beneath the conjunctiva. The ecchymosis does not, how- 
ever, in such cases appear directly after the accident, but only at 
an interval of several hours. 

. The ecchymoses are generally situated on the ocular portion of 
the conjunctiva in the vicinity of the cornea, or in the retro-tarsal 
fold. The effusion mostly gives rise to uniformly red patches, 
which vary in size and number, but it may be so considerable that 
it extends round the whole cornea. 

The treatment should consist chiefly in the application of stimu- 
lating lotions, e.g., Tr. arnic. 3j, Aq. dest. Eiv, to be applied to the 
eye, or a compress moistened with this lotion should be firmly tied 
over the eye ; indeed a firm compress bandage accelerates the ab- 
sorption of blood more than any other remedy. A poultice of 
black bryony root is also useful. ( 

(Edema of the conjunctiva is met with very frequently in the 
course of many inflammations of the conjunctiva and inner tunics 
of the eye, but it may also occur spontaneously, more especially in 
elderly, feeble persons, affected perhaps with disease of the kidney. 
The treatment should consist in the application of a firm bandage, 
and the use of mild astringent collyria. A few superficial incisions 
may be made in the chemosis with a pair of curved scissors. The 
health of the patient should be at the same time attended to. Dr. 
Lawson Tait 1 has called attention to the important fact that severe 
oedema of the conjunctiva is sometimes a symptom of surgical fever 
(pyaemia), being dependent on a thrombus in the cavernous or oph- 
thalmic sin us. 

Subconjunctival emphysema is caused by fracture of the nasal 
parietes, which admits the air into the subconjunctival tissue, or by 
a rupture in the lachrymal sac ; when the air is also admitted be- 
neath the conjunctiva, if the nose is blown. The nature of the 
affection may be recognized by the peculiar crackling which is 
heard when the swelling is pressed with the finger ; firm pressure 
causing it to disappear. A bandage should be applied, and, if 
necessary, the swelling may be pricked with a needle and the air 
allowed to escape. 

1 " Edinburgh Med. Journal," No. 45, p. 798. 



Chapter II. 
DISEASES OE THE CORNEA. 



1.— P ANNUS. 

This affection is characterized by a superficial vascular opacity 
of the cornea, occupying more or less of its expanse. [Fig. 33.] 

The opacity generally com- 
mences at the periphery, and 
gradually extends towards the 
centre, but the reverse may also 
occur. It is due to the forma- 
tion of a neo-plastic layer of 
cells beneath the epithelium, 
and also perhaps in the super- 
ficial layers of the cornea, just 
beneath the anterior elastic 
lamina (membrane of Bow- 
man). These neo-plastic cells 
show a tendency to become de- 
veloped into connective tissue 
'^WffB'MX-l (Wedl), and bloodvessels ap- 

/ jr i ^^j^ p ear amon g S t them. The 

^jjK , N Vv ^\ bloodvessels are situated be- 

\\^ J neath the epithelium, and also 

somewhat deeper, beneath the 
After t. w. Jones] anterior elastic lamina. On 

closer examination, they will 
be found to consist of two sets. The one is a direct continuation 
of the conjunctival vessels, and is almost entirely venous. It forms 
a large-meshed, tortuous network of vessels, covering a considerable 
portion, or perhaps even the whole of the cornea, which is seen to 
be opaque and hazy between the meshes. The other vessels, which 
are chiefly arterial, are straight and parallel, and lie beneath those 
from the conjunctiva. They proceed from the anastomosis between 
the conjunctival and subconjunctival vessels, at the limbus con- 
junctivae, where it forms a bright rosy zone. If the vascularity is 
considerable, these parallel vessels are very numerous, and give a 
very red appearance to the edge of the cornea, which is often also 
somewhat swollen. "When the cornea is extremely vascular and 
opaque, so that it assumes a very red or even fleshy appearance, 




PANNUS. 109 

the disease is termed " pannus crassus," whereas if the bloodvessels 
are few and scattered, and the cloudiness inconsiderable, it is called 
"pannus tenuis." 

In the acute form of the disease, there is often considerable pho- 
tophobia, lachryrnation, and ciliary neuralgia, accompanied by 
marked conjunctival and subconjunctival 'injection. But if the 
affection runs a very protracted and chronic course, the irritability 
of the eye is generally but slight, except if acute exacerbations 
occur. The surface of the cornea gradually becomes more opaque, 
rough, and irregular, and its epithelial layer hypertrophied and 
thickened, so that the cornea may finally assume almost a cuticular 
appearance. Or the epithelium may be shed at different points, 
giving rise to superficial facets and irregularities. But the loss of 
substance may extend much deeper, and extensive ulcers be formed, 
which may even lead to perforation of the cornea, and subsequently 
to anterior synechia, staphyloma, etc. After the pannus has existed 
for some time, the cornea is apt to become somewhat thinned, and, 
yielding gradually to the intra-ocular pressure, to lose its normal 
curvature and become bulged forward. This fact is of great prac- 
tical importance, for even although the cornea should hereafter 
regain much of its transparency, this faultiness in its curvature 
will produce considerable deterioration of vision. 

Amongst the causes which may produce pannus, granular oph- 
thalmia is by far the most frequent ; in fact, in the vast majority 
of those cases in which the opacity is confined to the upper half of 
the cornea, it is due to granular lids. When speaking of granular 
ophthalmia, I mentioned that pannus might be produced by the 
friction of the roughened surface of the lid on the cornea, or by a 
direct extension of the granulations on to the ocular conjunctiva, 
and from thence on to the cornea. In the latter case, small gray or 
yellow infiltrations appear near the margin of the cornea, and, if 
the attack be acute, may even extend over the whole of the cornea. 
Between these infiltrations bloodvessels are seen to be passing. 

Phlyctenular or purulent ophthalmia may also give rise to pannus. 
In the former case, the opacity and vascularity are not considerable 
in extent, and the affection is chiefly characterized by the appear- 
ance of scattered phlyctenulse, or small infiltrations on the surface 
of the cornea. 

The disease may likewise be produced by the constant friction 
and irritation of the cornea, caused by inverted eyelashes, with or 
without entropion, by cretification of the Meibomian glands (chal- 
azion), and by the desiccation and exposure of the cornea to external 
irritants, as in cases of lagophthalmus, etc. In such cases, the 
disease may be termed " traumatic pannus." In the chronic form, 
pannus may exist for many years without undergoing any particular 
change, except perhaps thinning and prominence of the cornea. 
Inflammatory exacerbations may, however, occur again and again, 
and each time leave the sight and the opacity of the cornea in a 
worse condition. 



110 DISEASES OF THE CORKEA. 

The prognosis is favorable in proportion as the pannus is incon- 
siderable and of recent origin, and the cause remediable. In very 
chronic cases, especially of the pannus crassus, the disease, even if 
eventually cured, generally leaves behind it extensive and dense 
opacities. If there is a central leucoma, or if iritis has occurred 
during the progress of the disease, and the pupil is closed, it will 
be necessary to perforin iridectomy. 

The treatment to be adopted must depend upon the cause, for if 
the latter can be cured, the pannus will also disappear. As I have 
already in the article upon granular ophthalmia entered very fully 
into the mode of treating pannus produced by that disease, I need 
not recur to this subject. In cases of traumatic pannus, our efforts 
must be at once directed to the removal of the cause, e.g., the en- 
tropion, inverted lashes, chalazion, etc. The opacity of the cornea 
which may remain after the disappearance of the original disease, 
must be treated by mild local irritants, amongst which may be es- 
pecially recommended insufflation of calomel, the application of the 
red or yellow precipitate ointment, vinum opii, oil of turpentine, 
sulphate of copper, etc. These applications hasten the absorption 
of the morbid products, by producing a temporary inflammatory 
congestion of the bloodvessels. 



2— PHLYCTENULAR CORNE1TIS (HERPES CORNER). 

This disease often accompanies phlyctenular ophthalmia. In 
fact, the two affections are alike in character, and demand a very 
similar mode of treatment. 

As in phlyctenular ophthalmia, the appearance of the vesicles on 
the cornea is generally preceded by a sensation of heat and itching 
in the eyelids, which is soon followed by conjunctival and subcon- 
junctival injection, photophobia, lachrymation, and ciliary neu- 
ralgia. The latter, which is often but slight when the affection is 
confined to the conjunctiva, is frequently very severe in herpes 

t| cornese. The same is the case with the 
[Fig. 34. I photophobia, which is often most in- 

i I I tense and persistent. The character- 

\ j k t I istic little phlyctenulse soon make their 

■k\ Mini. \ appearance on the surface of the cornea. 

§im^^M^». v; I [Fig. 34.] Their number and mode of 
l&N^fc i| distribution vary greatly. Sometimes, 

tJ&*^M^^$%* '§ tnere are kut one or two near the 
'vK^^^^^^^x*' m mar S" 1 °f t ,ne cornea, in other cases 
■/■ i>f>5~swy I tne y are more numerous, and are either 

''' I scattered freely over the surface of the 

( ) f I cornea 5 or are chiefly confined to one 

k/ j I part. Or again, they may be ranged 

^— ^ / along its edge in single file, surrounding 

After t. \v. JoDes.j I a more or less considerable portion of 

B the cornea like a string of beads. If 



PHLYCTENULAR CORNEITIS. Ill 

the phlyctenule are numerous, and extend over a considerable ex- 
panse of the cornea (pannus scrofulosus), the vascularity is general, 
and the cornea is surrounded by a bright, rosy zone of vessels ; 
whereas, if the pustules are confined to one portion of the cornea, 
the injection is generally also partial. Sometimes, the phlyctenula? 
are very superficial, and appear in the form of small, transparent 
vesicles or blisters, whose epithelial covering is soon shed, leaving 
a small excoriation, which may easily escape detection, and lead to 
an erroneous diagnosis and mode of treatment. Generally, how- 
ever, the phlyctenula is more apparent, and is imbedded in the 
cornea, its summit rising slightly above the surface. It appears 
in the form of a small, circumscribed, gray infiltration, surrounded 
by a zone of slightly opaque and swollen cornea, the latter being 
especially the case if several pblyctenulse are situated close together. 
At its apex a little transparent vesicle often forms, which bursts 
and leaves an excoriated surface, the bottom of which is opaque, 
and of a gray or grayish-yellow color. This excoriation may gradu- 
ally extend somewhat in circumference and depth, and assume the 
character of a small ulcer, which is especially apt to occur if the 
phlyctenula is situated near the centre of the cornea, and the affec- 
tion has been injudiciously treated by strong astringents. If no 
transparent vesicle forms at the apex of the phlyctenula, this 
becomes somewhat more opaque and infiltrated, and then, losing its 
epithelial covering, is changed into a superficial, yellowish-gray 
ulcer. These ulcers generally run a very favorable course if they 
are judiciously treated, and show little or no tendency to extend 
much, either in circumference or depth. The ulcer becomes covered 
by a layer of epithelium, and gradually fills up, and the cornea 
regains more or less of its transparency. But if the infiltrations 
are situated very close to each other, two or three may coalesce, and 
thus give rise to one extensive ulcer, which may increase in depth, 
and even lead to perforation. This may also occur if the infiltra- 
tions are situated somewhat deeply in the cornea, and if strong 
local irritants (nitrate of silver, sulphate of copper, etc.) are em- 
ployed. In the majority of cases there is no fear of this complica- 
tion, for under judicious treatment the excoriations or little ulcers 
soon fill up, the corneal substance is regenerated, and perhaps no 
opacity is finally left. In other cases, the result is not so favorable, 
for a more or less dense opacity may remain behind. 

There is great tendency to relapse. Just as the symptoms of 
irritation and vascularity are subsiding, the phlyctenulse disap- 
pearing, and the disease seems to be almost cured, all the acute 
symptoms of irritation return, a fresh crop of pustules makes its 
appearance, and a severe relapse takes place. This may occur again 
and again, and the affection gradually assume a chronic character ; 
vessels are developed upon the cornea, which run towards the infil- 
tration, and this condition might be mistaken by a superficial 
observer for that of fascicular corneitis. On closer examination 
it will, however, be seen that the bloodvessels are few in number, 
and more scattered, not rising prominently above the surface of 



112 DISEASES OF THE CORNEA. 

the cornea, and not pushing along the infiltration before them, but 
rather stopping short of it. When numerous phlyctenulse are 
crowded together on the cornea, and interspersed with bloodvessels, 
it is often termed " herpetic or scrofulous" pannus, more especially 
if they are situated in the upper half of the cornea. 

The causes which may produce this affection are the same as 
those which give rise to phlyctenular ophthalmia, and it also occurs 
most frequently amongst children and young persons of a weakly, 
scrofulous constitution, and nervous, excitable temperament. 

The treatment should also be similar to that which was recom- 
mended for phlyctenular ophthalmia. I must here lay the greatest 
stress upon the necessity of avoiding the use of caustics, more espe- 
cially the nitrate of silver, for this greatly increases the irritability 
of the eye, aggravates the character of the disease, and augments 
any tendency to necrosis and breaking down of the corneal tissue. 
It may also cause the inflammation to extend to the iris and ciliary 
body. Indeed it may be laid down as a rule, that in all affections 
of the cornea, except those of a very chronic character, the use of 
caustics should be most strictly avoided. In phlyctenular corneitis 
our chief endeavor must be to diminish the great irritability of the 
eye, to prevent the extension of the phlyctenulse or ulcers, and to 
facilitate and assist the regeneration of the corneal tissue. The 
agent which we shall find of the greatest service for these purposes 
is atropine. Indeed this remedy is invaluable in the treatment of 
affections of the cornea and iris. It exerts a beneficial influence 
upon the cornea by acting as a local anaesthetic during its passage 
through the cornea into the aqueous humor, thus greatly dimin- 
ishing the irritability of the cornea and of the ciliary nerves. 
This is often witnessed when a drop of atropine is applied to an 
eye affected with acute corneitis, accompanied by intense symptoms 
of irritation ; for if such an eye is examined half an hour after the 
application of the atropine, we find a very marked diminution in 
all these symptoms ; the patient expressing himself greatly relieved. 
The atropine also acts by decreasing the intra-ocular tension, and 
thus relieving the cornea of a certain degree of pressure ; hence its 
nutrition and the regeneration of its substance are greatly facili- 
tated. This diminution in the intra-ocular tension is of special 
advantage in deep ulcers of the cornea, as will be readily under- 
stood when we remember that the thinnest portion of the cornea 
(the bottom of the ulcer) has to sustain the same degree of intra- 
ocular pressure as the healthy part. 1 The solution of atropine (gr. 

' I must, however, strongly insist upon the absolute necessity of the solution of 
atropine being quite pure, and perfectly free from any admixture of strong acid or 
spirits of wine. A few drops of strong sulphuric acid are sometimes added by 
chemists when the sulphate of atropine is not quite neutral, and therefore imper- 
fectly soluble. I have met with several instances in which a pure solution of atro- 
pine proved of the greatest benefit in allaying the irritability of the eye and in 
alleviating the inflammation, and in which a fresh supply of atropine (made up 
after the same prescription, but obtained from a different chemist) has at once set up 
severe irritation of the eye, accompanied by considerable pain, redness, lachryma- 
tion, etc., but these symptoms soon disappeared again on the use of a pure solution 



PHLYCTENULAR CORNEITIS. 113 

ij ad 3j of water) should be applied to the eye three or four times 
a day. If it should, after a time, be found rather to increase than 
alleviate the irritation, a collyrium of belladonna must be substi- 
tuted. If it has already produced considerable irritation of the 
conjunctiva and a crop of vesicular granulations, an astringent 
collyrium of alum, borax, or nitrate of silver (gr. j ad ,?j) should be 
employed. The belladonna ointment is to be rubbed on the fore- 
head three or four times daily, until a slight papular eruption is 
produced. If there is much pain in and around the eye, and more 
especially if the latter is very painful to the touch, much relief is 
often experienced from the application of two or three leeches to 
the temple, or a blister should be applied behind the ear. If, to- 
gether with the photophobia and lachrymation, the temperature of 
the lid is much increased, I have often found very marked benefit 
from the periodical application of cold compresses. These are to 
be applied three or four times a day, for a space of 20 to 30 minutes, 
and are to be changed every two or three minutes, as soon as they 
get the least warm. The photophobia is often, however, very ob- 
stinate and intractable. When it is chiefly due to an abrasion of 
the epithelium and exposure of the corneal nerves, a compress band- 
age should be applied. But sometimes it resists all remedies, and 
a severe spasm of the lids (blepharospasm) remains even after the 
affection of the cornea is cured. In such cases the different reme- 
dies which I have mentioned in the article on phlyctenular oph- 
thalmia, should be tried, v.iz., subcutaneous injection of morphia, 
immersion of the face in cold water, and if all these fail, and the 
spasm is arrested by pressure upon the supra-orbital nerve, we must 
have recourse to a division of this nerve. I have often found that 
a prolonged stay at the sea-side, together with sea-bathing, tonics, 
a generous diet, and plenty of out-of-door exercise will cure cases 
of photophobia, which have obstinately resisted all other remedies. 
Small doses of tartar emetic sometimes prove useful in alleviating 
the photophobia and ciliary irritation during the acute stage of the 
disease. But this remedy should not be persisted in if it does not 
produce any benefit in the course of a few days, as its prolonged 
use is apt to weaken and debilitate the patient. Arsenic has also 

of atropine. On examination, the impure solution was found to contain a small 
quantity of strong sulphuric acid. Such cases as this completely disprove the 
theory that a small quantity of strong acid or of alcohol can have no prejudicial 
effect upon the eye, even although there may be much ciliary irritation and a severe 
inflammation of the cornea or iris. I must state, however, that we occasionally 
meet with exceptional cases, in which there exists a peculiar idiosyncrasy which 
renders the patient most intolerant of the use of even a weak and perfectly pure 
solution of atropine. I have seen instances in which a drop of a weak and quite pure 
solution of atropine has produced great irritation and pain, or even an erysipelatous 
condition of the eyelids and cheek, accompanied by redness and chemotic swelling 
of the conjunctiva. This is, however, a very exceptional occurrence, and hears 
not the least analogy to those cases in which the irritation is caused by the impurity 
of the atropine, for in such, a pure solution is not only well borne, but greatly 
alleviates the ciliary irritation and inflammatory symptoms. Mr. Lawson also 
mentions some interesting instances of this peculiar idiosyncrasy, in a paper in the 
"R. L. 0. H. Reports," vi. 119. 
8 



114 DISEASES OP THE CORNEA. 

been strongly recommended in this form of corneitis, on the sup- 
position of its similarity to eczema. This remedy often proves very 
serviceable, especially if the corneitis is accompanied by an ecze- 
matous eruption of the forehead and face. In the latter case the 
lotion of acetate of lead and glycerine (p. 85) should be applied to 
the face ; or the following lotion may be used for the same purpose: 
B. Boracis 5ij, Glycer. 3ss, Aq. sambuci gij, Aq. dest. ad Sviij. A 
powder containing oxide of zinc may be dusted over the face. The 
patient's general health should be attended to, and if he is of a 
weakly and scrofulous habit, tonics, cod-liver oil, and a nutritious 
and generous diet, together with the use of ale and wine, should 
be prescribed. The bowels should be kept well regulated, and 
special attention should be paid to the free action of the skin, as 
this exerts a marked influence upon the symptoms of ciliary irri- 
tation, especially the photophobia. When the acute symptoms 
have subsided, we must have recourse to the insufflation of calomel, 
and if this is well borne the yellow oxide of mercury ointment 
(gr. j — ij ad 3j) should be applied ; this will not only hasten the 
absorption of any remaining opacity, but check the tendency to 
relapses. In chronic and very obstinate cases, especially if they are 
accompanied by much vascularity of the cornea, great benefit is 
often experienced from a seton. 

In rare instances, we meet with a peculiar formation of transpa- 
rent vesicles upon the surface of the cornea, which are produced by 
slight elevations of the epithelial layer and the anterior elastic 
lamina from the surface of the cornea proper. The appearance 
presented by these little blisters is very characteristic, and is gener- 
ally accompanied by very severe symptoms of irritation, especially 
photophobia and lachrymation. These symptoms subside when 
the vesicles burst, but a fresh crop of the latter is generally formed 
every three or four days. In a case mentioned by Mooren the 
disease assumed the character of a regular tertian type, and was 
cured by the energetic use of quinine ; indeed this remedy, com- 
bined perhaps with steel, should be given in all cases ; atropine and 
a compress bandage being applied to the eye. 



3— FASCICULAR CORNEITIS. 

This peculiar form of corneitis, which is very common in Ger- 
many, is extremely rare in England, for whilst I saw many instances 
of it in Berlin, I only remember having met with four pure cases 
in England during the last eight years. 

The symptoms of this affection are very characteristic and easily 
recognized. The attack is generally ushered in by considerable 
photophobia, lachrymation, and ciliary neuralgia. On examining 
the eye, the ocular conjunctiva is found to be injected, and there is 
also seen a bright rosy zone of subconjunctival vessels round the 
cornea. Near the edge of the latter may perhaps be noticed at one 
spot a few small phlyctenules, and thelimbus conjunctivae is at this 



FASCICULAR CORNEITIS. 115 

point also somewhat swollen. The parallel subconjunctival vessels 
are seen at this spot to pass on to the cornea and extend more or 
less on to its surface, forming a narrow bundle or leash of vessels 
(hence the term " fascicular" corneitis), which lies in a somewhat 
swollen and elevated portion of the cornea. This fasciculus of 
vessels consists both of veins and arteries ; at its apex, and rising 
somewhat above the level of the vessels, is noticed a small, cres- 
centic, yellowish-gray infiltration, surrounded by a somewhat 
opaque and swollen portion of cornea. As the disease progresses, 
the infiltration is gradually pushed further and further on to the 
cornea in front of the vessels ; its epithelial covering is shed, it 
assumes a yellowish tint and becomes changed into a small super- 
ficial ulcer. In some instances the original leash of vessels may 
bifurcate, so that it assumes a Y shape, having a separate infiltra- 
tion at each apex. The disease may extend far on to the cornea, 
and prove dangerous from its leaving a dense opacity in the centre 
of the cornea just over the pupil ; but the ulcer generally remains 
superficial, and does not extend very deeply into the cornea or lead 
to perforation. During the progressive stage, the symptoms of irri- 
tation are very marked and obstinate. When the disease has reached 
its acme, it generally remains stationary for some little time (per- 
haps even several weeks) and then gradually diminishes in intensity 
and slowly retrogrades, the symptoms of irritation rapidly disap- 
pearing. The time which elapses during these several stages, will 
depend upon the size of the fasciculus of vessels and of the infiltra- 
tion. The vascularity gradually diminishes, the ulcer is again 
covered by a layer of epithelium, and begins to fill up from the 
periphery towards the centre ; the corneal tissue is more or less 
regenerated, and after a time but little opacity may be left. 

This disease is generally due to the same causes as phlyctenular 
ophthalmia, and is most frequently met with in weakly and scro- 
fulous persons, and in them it is very apt to run a most protracted 
course. 

' If the symptoms of irritation are very acute, only soothing reme- 
dies should be applied. Atropine should be dropped into the eye, 
the compound belladonna ointment should be rubbed in over the 
forehead, a blister should be applied behind the ear, and a leech or 
two to the temple if the eye is very painful to the touch. If the 
vascularity is very marked and the case severe, benefit is often 
derived from dividing the bundle of vessels close to the cornea,, 
either with a small scalpel or a pair of curved scissors ; for after 
this has been done, the bloodvessels on the cornea and the infiltra- 
tion are found to shrink and diminish in size. When the acute 
symptoms of irritation have considerably subsided, the insufflation 
of calomel should be at once commenced, or the yellow oxide of 
mercury ointment (gr. ij — viij ad 3j) should be applied. Both these 
remedies, but moreespecirlly the yellow oxide, are almost specifics 
for this disease. The ointment may be applied from the very com- 
mencement, if the symptoms of irritation are not very marked ; it 
must, however, be used with care, and its effect should be closely 



116 DISEASES OF THE CORNEA. 

watched. If we find the next day that it has excited considerable 
redness and irritation, its use should be temporarily abstained from, 
and calomel should be substituted. It is also of much use in check- 
ing the tendency to relapses, in cutting these short, and in hastening 
the absorption of the corneal opacity. Frequently, we must ring 
the changes between the ointment and the calomel, as after a time 
they temporarily lose some of their effect. 

A seton at the temple sometimes also proves of much benefit in 
this affection, not only in shortening the course of the disease, but 
also in preventing the occurrence of relapses. 



4.— SUPPURATIVE CORNEITIS. 

Practically, it is of importance to distinguish two principal forms 
of suppurative corneitis. The one is accompanied by more or less 
marked inflammatory symptoms, whilst in the other these are en- 
tirely absent, and the chief danger of the disease is found in their 
absence, as the suppuration spreads very rapidly and an extensive 
abscess or slough of the cornea speedily ensues. These two forms 
also demand a totally opposite plan of treatment. In the inflam- 
matory, we must endeavor to check and subdue the symptoms of 
irritation and inflammation by local antiphlogistics ; whereas in 
the torpid, non-inflammatory form, we must most carefully eschew 
such treatment, and at once attempt to produce a certain degree of 
inflammation, in order to check the tendency to necrosis and puru- 
lent infiltration. 

"Whilst drawing special attention to these two opposite types of 
the disease, I must state that in practice we constantly meet with 
mixed forms, showing some of the symptoms of each type. Indeed 
the surgeon will chiefly display his skill and judgment, by distin- 
guishing whether any of the symptoms have attained an undue 
prominence and require to be checked in order that a just balance 
may be maintained between the necessary degree of inflammation 
and the suppurative condition of the cornea ; so that whilst on the 
one hand, the inflammatory symptoms are not allowed to become 
excessive, they are, on the other, not too much suppressed. 

The inflammatory suppurative corneitis is often accompanied by 
great photophobia, lachrymation, and intense ciliary neuralgia ; 
there is also much conjunctival and subconjunctival injectionj the 
cornea being surrounded by a bright rosy zone, accompanied per- 
haps by some chemosis. On account of the irritation of the ciliary 
nerves, the pupil is often greatly contracted. On examining the 
cornea, we notice a small circumscribed infiltration, which is gene- 
rally situated near the centre, but sometimes at the periphery of 
the cornea. Its position varies, sometimes it is situated in the 
superficial layers of the cornea, and then the latter may become 
somewhat raised above the level at this point, or it may lie in the 
central or deeper portion of the cornea, in which case the surface 
remains unaltered. The infiltration soon increases in density and 



SUPPURATIVE CORNEITIS. 117 

assumes a creamy yellowish-gray color, being surrounded by a well- 
marked line of demarcation in the form of a light gray zone, which 
gradually shades off into the transparent cornea ; the latter also shows 
a certain degree of inflammatory swelling at the point occupied by 
this zone. The epithelium may be shed, and a portion of the con- 
tents of the infiltration break down and be thrown off, so that a 
more or less deep ulcer is formed. Although the subconjunctival 
vessels may pass slightly on to the cornea, they never reach the 
ulcer, even when this is situated near the periphery. When it is 
in the centre of the cornea, the latter appears quite free from blood- 
vessels, except a few which may just pass over its margin. The 
retrogressive stage generally soon sets in, the infiltration changes 
its 3 r ellow hue for a light gray tint, and becomes gradually ab- 
sorbed, leaving perhaps hardly any opacity behind. The disease 
as a rule shows a tendency to remain localized, and not to extend 
superficially, but rather in depth. Relapses are apt to occur and 
the affection may thus assume a chronic character. 

But the disease does not always run so favorable a course. Thus, 
several superficial infiltrations may be formed close to each other, 
and, gradually extending in circumference and depth, may coalesce 
and thus give rise to a considerable abscess of the cornea. Their 
contents undergo suppurative and fatty degeneration, the cells and 
nuclei break down, the infiltration assumes a yellow color, being 
surrounded, however, by a grayish-white zone of demarcation. If 
this occurs near the centre of the cornea, it may prove dangerous 
from its leaving a dense opacity just over the pupil, or from its 
perhaps leading to an extensive slough of the cornea. Again, if 
the infiltration is situated deeply in the cornea, it may lead to per- 
foration of the latter, or give rise to onyx, hypopyon, and iritis. 
The pus may sink down between the lamellae of the cornea to its 
lower margin, and thus produce a peculiar opacity, termed onyx or 
unguis, on account of its supposed resemblance to the white lunula 
of the finger-nail. If the onyx is but small, and confined to the 
very edge of the cornea, it may easily be overlooked, more espe- 
cially if it be somewhat covered by the swollen limbus conjunctivae. 
If it is more considerable, so that it reaches nearly up to one-third 
of the cornea, or even higher, it may be mistaken for an hypopyon. 
But on careful examination (more especially with the oblique illu- 
mination) it will not be difficult to distinguish it from the latter, 
for it will be seen to lie on the corneal side of the anterior chamber, 
a portion of transparent cornea perhaps dividing it from the latter, 
and it is situated at some distance from the iris. But the differ- 
entia] diagnosis is of course more difficult if, as is sometimes the 
case, an hypopyon coexists with the onyx. 

The hypopyon which not unfrequently accompanies suppurative 
corneitis (more especially the non-inflammatory form) may be pro- 
duced either from the iris or from the cornea in the following 
ways : — • 

1. An inflammation of the iris may supervene upon the corneitis, 



118 DISEASES OF THE COKNEA. 

lymph be effused into the aqueous humor, and, falling to the 
bottom of the anterior chamber, thus produce an hyp 1 opyon. 

2. The abscess may perforate the cornea, and its purulent con- 
tents be carried into the aqueous humor and be precipitated at the 
bottom of the anterior chamber. Sometimes such a mode of pro- 
duction of hypopyon is completely overlooked, from the fact that 
the communication between the anterior chamber and the abscess 
in the cornea is not large and direct, but is brought about by a 
small sloping canal, through which the contents of the abscess 
have made their way into the anterior chamber. Special attention 
has been called to this fact by Weber, 1 who has, moreover, fre- 
quently passed a minute probe from the ulcer through the canal 
into the anterior chamber, and thus verified the communication. 
"With the oblique illumination, this little canal appears like a white 
streak, running from the abscess to the anterior chamber. 

3. When the abscess is situated deeply in the cornea, near the 
membrane of Descemet, inflammatory proliferation and fatty de- 
generation of the epithelial cells, lining the posterior portion of the 
cornea, may occur. They are thrown off, and, mixing with the 
aqueous humor, render this turbid, and if these deposits are con- 
siderable in quantity, they may fall down to the bottom of the 
anterior chamber and thus produce an hypopyon. It has been also 
supposed that the latter is often due to a transudation of some of 
the contents of the deep-seated abscess into the aqueous humor. 2 
Weber, however, asserts that he has never met with an instance in 
which the communication between the abscess and the anterior 
chamber could not be distinctly proved by means of probing. I 
have, however, met with cases of abscess in the middle portion of 
the cornea, which have been accompanied by an infiltration situated 
at the membrane of Descemet, and an hypopyon evidently pro- 
duced by the latter (for there was no iritis), and in which I have 
failed, on the most careful examination by the oblique illumination, 
to trace any communication between the abscess and the posterior 
infiltration. 

Inflammatory suppurative corneitis is met with in severe and 
aggravated cases of phlyctenular corneitis, and also in severe cases 
of purulent, granular, and diphtheritic ophthalmia. It is very 
frequently caused by mechanical and chemical injuries, such as the 
lodgment of chips of steel, a bit of wheat ear, etc., in the substance 
of the cornea, which perhaps remain there undiscovered. This is 
especially the case in old or very feeble persons. It may also follow 
operations upon the eye, more particularly those for cataract. 

In the milder cases of inflammatory suppurative corneitis, atro- 
pine should be applied three or four times daily, and the compress 
bandage employed. If there is much irritability and ciliary neu- 
ralgia, and if the eye is very painful to the touch, two or three 
leeches should be applied to the temple. Subcutaneous injections 
of morphia may also be employed with great advantage. If the 

' " A. f. 0.," viii. 1, 322. 2 Roser, ibid., ii. 2, 151. 



SUPPURATIVE CORNEITIS. 119 

abscess resists all treatment, great benefit is often derived from 
slightly opening it with the point of an extraction knife. But 
if it is deep seated, and threatens to perforate the cornea, paracen- 
tesis should, be performed by passing a fine needle into the anterior 
chamber through the bottom of the abscess. If a considerable 
hypopyon exists, paracentesis should also be performed, but with a 
broad needle, the object of the operation being not so much to re- 
move the lymph from the anterior chamber as to diminish the 
intra-ocular pressure, and thus to arrest the progress of the disease, 
to hasten the absorption of the infiltration, and facilitate the re- 
generation of the corneal tissue. This operation may have to be 
repeated several times (vide treatment of ulcers of the cornea by 
paracentesis). In order to diminish the intra-ocular pressure still 
more completely, and more effectually to subdue the inflammation, 
it may be very advisable to perform iridectomy in cases, in which 
suppurative corneitis is extensive, threatens perforation, and is ac- 
companied by hypopyon. This is more especially the case if the 
abscess is deep, and situated in the centre of the cornea, ~for even 
if it should not perforate, it will leave a dense leucoma, which will 
subsequently necessitate the formation of an artificial pupil. It 
is, therefore, much wiser to make an iridectomy at once, as this 
will exert a beneficial influence upon the course of the disease, and 
leave an artificial pupil opposite a clear portion of the cornea. , 

In the non-inflammatory suppurative corneitis there is generally 
a very marked absence of all the usual symptoms of irritation and 
inflammation. There is no photophobia, lachrymation, or pain, 
and the eye appears, in fact, abnormally insensible to external 
irritation (bright light, etc.). It may, however, supervene upon a 
circumscribed infiltration of the cornea, accompanied by severe 
symptoms of irritation and intense ciliary neuralgia. These symp- 
toms suddenly yield, and the abscess shows a tendency to necrosis, 
extending quickly in circumference and depth. There is formed 
very rapidly, often in the course of a few hours, in the centre of 
the cornea, a small yellow spot, which is sharply defined against 
the clear and transparent cornea, and is not surrounded by an 
opaque gray zone, as is the case with the inflammatory infiltration. 
Indeed, the adjoining portion of cornea may even appear abnor- 
mally lustrous, which is probably due to serous infiltration. The 
yellow color is also more deep and pronounced than in the inflam- 
matory form. The disease rapidly extends in circumference, and 
consecutive yellow layers are formed around the original infiltra- 
tion. The tissue of the cornea becomes quickly broken down, 
undergoes fatty degeneration, and pus-cells are formed in large 
quantity, and the abscess soon gains a considerable extent, both 
on the surface and in depth, reaching, perhaps, nearly to the mem- 
brane of Descemet. When the suppuration has attained a certain 
depth , the epithelial cells lining the membrane of Descemet undergo 
inflammatory proliferation, and, being thrown off, mix with the 
aqueous humor, rendering this turbid, and perhaps sinking down 
in the anterior chamber in the form of an hypopyon. The iris 



120 DISEASES OF THE CORNEA. 

becomes swollen, hypersemic, and of a yellowish -red color, due 
probably in part to the hyperemia, and in part to a purulent in- 
filtration of its tissue. There are generally no firm adhesions be- 
tween the edge of the pupil and the capsule of the lens. The 
tendency of this non-inflammatory form of suppurative corneitis 
is to extend rather in circumference than in depth, so that it leads 
to very considerable opacity or even extensive suppuration of the 
cornea, with all its dangerous consequences. 

When the process of reparation sets in, we find that the yellow 
and sharply defined infiltration becomes surrounded by a grayish 
zone, and that there is at the same time an increase in the vascu- 
larity of the eye. Much of the danger is now past, for the disease 
assumes more of the character of inflammatory suppurative corneitis 
and shows a tendency to become limited, and there is, consequently 
much less fear of purulent necrosis and sloughing of the cornea. 
Gradually the yellow color is changed to a whitish-gray, the puru- 
lent infiltration breaks down and is absorbed, and the corneal tissue 
is regenerated. It may, after a time, even regain its normal trans- 
parency, especially in children, and if the infiltration was but small 
and superficial. Otherwise, a more or less dense opacity is left 
behind, which, if it be situated in the centre, may cause great im- 
pairment of vision. But if a sufficient portion of the margin of 
the cornea is transparent and of normal curvature, excellent sight 
may often be restored by the formation of au artificial pupil. But, 
unfortunately, so favorable a result is not always obtained in severe 
and extensive suppurative corneitis. Perforation of the cornea but 
too frequently takes place, followed by anterior synechia or staphy- 
loma, or the inflammation extends to the other tissues of the eye- 
ball, and panophthalmitis occurs, ending in atrophy of the globe. 

Non-inflammatory suppurative corneitis occurs frequently in 
very aged and feeble persons, more especially after operations 
involving the cornea (such as those for cataract, particularly the 
flap extraction), or after injuries to the cornea from foreign bodies 
striking it or becoming lodged on its surface or in its substance. 
Thus, it is not unfrequently met with amongst aged country people, 
if a bit of wheat ear, or, perhaps the wing of an insect, becomes 
imbedded in the cornea and is not removed at once. I have seen 
it produced in some instances by a simple concussion from a blow 
against the eye by a bit of wood, the bough of a tree, etc., without 
any wound of the cornea. Von Graefe has also described (A. f. 0., 
12, 2,250) cases of suppuration of the cornea occurring in infants 
suffering from encephalitis. 1 It may likewise supervene upon severe 
constitutional diseases, which have greatly weakened the general 
health, such as typhus fever, cholera, 1 " encephalitis, diabetes, etc. 

It may also follow paralysis of the fifth nerve, and is then termed 
neuro-paralytic ophthalmia. The affection of the cornea is gener- 
ally chronic, and occurs some time after the paralysis. If the latter 
is partial, the cornea is but rarely affected, and then only partially, 

1 Vide also Hirschberg's article "Berl. Klin. Wochenschrift," 1868, No. 31. 



SUPPURATIVE CORNEITIS. 121 

and not to a severe extent. The eye loses its sensibility, so that 
when irritants (e. g., astringent colly ria) are applied to it, they 
excite redness, but no feeling of pain or discomfort, indeed their 
presence is unfelt. The cornea then becomes opaque, ulcers may 
form, and suppuration may take place, leading perhaps to perfora- 
tion, hypopyon, etc., and the inflammation may even extend to the 
iris. The epithelium of the cornea and conjunctiva becomes rough 
and desiccated, so that a certain degree of xerophthalmia is pro- 
duced. One very interesting fact is, that paralysis of the fifth 
nerve always produces a diminution of the intra-ocular tension, and 
this is a point of the utmost importance with regard to the whole 
question of glaucoma and increased intra-ocular tension. 

The affection of the cornea which may ensue upon paralysis of 
the fifth nerve is apparently not due to mal-nutrition of the part, 
but simply to mechanical injuries, caused by the action of external 
irritants (dust, sand, etc.) to which the eye is exposed, and whose 
presence, on account of its insensibility, it does not resent or feel. 
That this is so, has been uncontrovertibly proved by the experi- 
ments of Snellen 1 and others. Snellen divided the fifth nerve in 
rabbits, and sewed their ears over their eyes, so as to protect the 
latter from all external irritants, and he found that when this was 
done the cornea did not become affected, whereas it began to 
become opaque the very day after the eye was left uncovered. 
More lately he has reported 2 a very interesting case, which fully 
bears out this view. A man, 36 years of age, was affected with 
complete paralysis of the left fifth nerve, together with paralysis of 
the sixth nerve of the same side. In consequence of the latter, there 
existed a convergent squint of the left eye, and on the outer side 
of the cornea there was a superficial ulcer, surrounded by a tolerably 
broad gray zone. The eye was quite insensible, and the acuteness 
of vision diminished to 5 ' ' v , and its tension was much decreased. 
In order to ascertain with certainty whether the affection of the 
cornea was due to mal-nutrition of the eye, or to its exposure to 
external irritants, Snellen fastened, by means of strips of plaster, a 
stenopaic shell over the eye, in order to protect it. A small central 
aperture was left for the patient to see through, so that he might 
ascertain whether the shell retained its proper position, for from the 
want of sensibility of the eye, he could not determine it otherwise. 
The shell was removed twice a day in order that the eye might be 
washed and cleansed. The improvement in the condition of the 
cornea and the sight was very marked, for within two days the 
vision = f J, and the cornea cleared so rapidly, that in eight days 
after the application of the shell the acuteness of vision was normal, 
viz., = |#. Only a small opacity remained at the outer side of the 
cornea, but the loss of sensibility and the diminished tension con- 
tinued. The application of turpentine and nitrate of silver produced 
the same symptoms of congestion as in a normal eye, without, how- 
ever, being felt by the patient. The stenopaic cup was left off, 

1 " Virchow's Archiv.," vol. 13, 1858. * " Jaarlijksch Verslag, etc.," 1863. 



122 DISEASES OF THE CORNEA. 

and the eye exposed; within two days the eye became again more 
inflamed, and the vision became diminished to j^. It shortly 
regained its normal standard after the reapplication of the shell. 

Meissner 1 is, however, of opinion that this tendency to inflamma- 
tion of the cornea is not altogether due to the loss of sensibility, 
for he has observed three cases 2 in which no corneitis ensued after 
division of the ophthalmic branch of the fifth nerve, although the 
eye was quite insensible, and not guarded against external irritants. 
On examination, it was found that in all these instances the inner- 
most portion of the nerve had escaped division. He, therefore, 
considers it probable that the fibres of this portion of the nerve 
render the eye more able to resist the effect of external irritants, 
etc. This supposition is strengthened by another case, in which 
Meissner incompletely divided the fifth nerve in a rabbit, and, 
although the sensibility of the eye was not impaired, the inflam- 
mation of the cornea ensued in the customary manner. On exami- 
nation, it was found that only the median (innermost) portion of 
the nerve had been divided. Schiff 3 has repeated these experiments 
with exactly the same results. 

The very dangerous character of non-inflammatory suppurative 
corneitis is chiefly due to the rapidity with which the infiltration 
extends, more especially in circumference, and to the great tendency 
to purulent necrosis of the corneal tissue, which leads but too fre- 
quently to very extensive suppuration of the cornea, or even to 
purulent disorganization of the eyeball. This disease proves espe- 
cially disastrous if it be treated by the ordinary antiphlogistics, 
e. g., cold compresses, leeches, etc., more particularly in severe cases. 
Thus Von G-raefe found that when he pursued this mode, of treat- 
ment he lost about three-fourths of the severer cases; "Whereas 
his_ success was very marked as soon as he substituted warm fomen- 
tations and the compress bandage. The object of the warm fomen- 
tations is to excite a certain degree of inflammatory reaction and 
swelling in the conjunctiva and cornea ; for in the total absence of 
these is to be sought the chief danger of the disease. They also 
hasten the limitation of the suppuration, expedite the absorption 
of the infiltration, and favor the process of reparation. After their 
application the eye becbmes more injected, and this is accompanied 
by inflammatory swelling of the conjunctiva. The vascularity also 
extends more or less on to the cornea. The infiltration is no longer 
sharply defined against the transparent cornea, but a gray halo 
appears around it, and this portion of the cornea is somewhat 
swollen, and the line of demarcation soon becomes well marked. 
If an hypopyon exists, and is not very considerable in extent, we 
often find that it becomes rapidly absorbed after the use of warm 
fomentations. Von Graefe 4 generally uses warm camomile fomen- 

• Henle and Pfeuffer's " Zeitschrift" (3), xxix. 96. 
2 These experiments were made on rabbits, 
a Henle and Pfeuffer's "Zeitschrift" (3), xxxix. p. 217. 

« "A. f.-O" vi. 2. 133. Vide also the author's abstract of this paper in " Roy. 
Lond. Ophth. Hosp. Reports," vol. iii. 128. 



SUPPURATIVE CORNEITIS. 123 

tations, varying in temperature from about 90° to 104° of Fahren- 
heit, according to the condition of the eye. The less the symptoms 
of inflammatory irritation, the higher should the temperature be. 
They should be changed every five minutes, and their use suspended 
for one quarter in every hour. The temperature should be lowered 
and the fomentations changed less frequently, or a longer interval 
be allowed to elapse between their application, as soon as the zone 
of demarcation and the inflammatory swelling make their appear- 
ance, and the necrosed portions of cornea begin to be thrown off. 
If these points are not attended to, we may set up too great an in- 
flammatory reaction, so that it may even become necessary to check 
it by antiphlogistic applications (cold compresses, leeches, etc.). 
Saemiseh, 1 who has extensively studied the effect of warm fomen- 
tations, advocates their continuation for a somewhat longer period 
in certain cases, in order to promote the exfoliation of the necrosed 
portions, and to expedite the absorption of the morbid products. 
Their effect must then, however, be closely watched, in order that 
too much inflammation is not set up. Indeed, the employment of 
warm fomentations requires great circumspection and attention, and 
cannot be entrusted to a stupid or careless nurse, for if they are 
applied too hot, changed too frequently, or continued too long, they 
may produce an excess of inflammation ; or if, on the other hand, 
they are permitted to get cold, they are even still more injurious, 
by diminishing the vitality of the part, and thus increasing the 
tendency to necrosis. Where I cannot rely upon the care and atten- 
tion of the nurse, I am in the habit of ordering the occasional use 
of warm poppy or camomile fomentations at stated periods ; for 
instance, three or four times a day for the period of half an hour; 
the fomentations being changed every five minutes during that 
time. In this way considerable benefit may be derived from their 
use, without incurring any risk. 

Warm fomentations are indicated in all forms of non-inflamma- 
tory suppurative corneitis, whether of spontaneous origin, or caused 
by inj uries to the eye or operations (especially those for the removal 
of cataract). They may also be necessary in cases of inflammatory 
suppurative corneitis if the symptoms of inflammation have sunk 
below a certain point. 

Great advantage is also experienced from the use of a firm com- 
press or the "pressure bandage" (vide p. 31), for this is of much 
service in limiting the extent'of the suppuration and hastening the 
formation of the zone of demarcation. Its application should alter- 
nate with the warm fomentations. 2 Even a certain degree of iritis 
does not contra-indicate its use. According to Von Graefe, it is 
not, however, applicable in those cases in which the purulent ne- 
crosis occurs rapidly, after the sudden cessation of severe symptoms 
of irritation and ciliary neuralgia, with which the disease was 
ushered in. After the pain had been alleviated by a subcutaneous 

1 "Klinische Beobachtungen von Pagenstecher and Saemiseh," 2, 102 ; 1862. 

2 " A. f. O.," vol. ix. 2, 151. 



124 DISEASES OF THE CORNEA. 

injection of morphia, and warm fomentations had been applied, 
Von Graefe found much benefit from the use of chlorine water. 1 
If there is any iritis and the aqueous humor is turbid, with or 
without the presence of hypopyon, it is most advisable to perform 
iridectomy without delay. This will generally at once cut short 
the progress of the disease and stop the extension of the suppura- 
tion. But if it is found that this improvement is but temporary, 
and lasts but for a few days, Von Graefe advises that the chlorine 
water should be again applied. He has done this even within 
thirty hours after the operation, if fresh crescentic infiltrations 
showed themselves around the original abscess, and he found that 
their extension was decidedly and markedly checked by this remedy. 

In the neuro-paralytic form of corneitis, a light bandage should 
be applied over the eye so as to protect it against all external irri- 
tants. It should be removed two or three times daily, and the eye 
washed and cleansed. If the case be seen sufficiently early and 
before any considerable mischief has been done, this remedy will 
generally suffice rapidly to cure the aft'ection of the cornea. 

Atropine drops should always be applied, as they not only act as 
an anodyne, but also diminish the intra-ocular tension. They are 
of especial importance if there is any iritis. Dr. "Warlomont speaks 
very highly of the use of Van Eoosbroeck's ointment in cases of 
indolent, necrotic corneal ulcers. Its composition is as follows : 
Sub-sulphate of mercury gr. 4, 6, or 8, Axun'g 3jss, Bals. peruv. 9 
lbs. 6 to 10. 

If perforation of the cornea appears imminent, and the ulcer is 
not of considerable, size, a paracentesis should be made with a fine 
needle through the bottom of the ulcer, so as to allow the aqueous 
humor to flow off very slowly. This will diminish the intra-ocular 
tension and facilitate the absorption of the infiltration, and the 
filling up of the ulcer. But if the infiltration or ulcer is deep 
seated, of considerable extent, and shows a tendency to increase 
still more, or to perforate the cornea, paracentesis should be at 
once performed. It is also indicated if a certain degree of hypo- 
pyon is present, with or without iritis. It has been already stated 
that our object in tapping the anterior chamber is less to remove 
the lymph than to diminish the intra-ocular pressure, and thus to 
stop the progress of the disease, hasten the absorption of the morbid 
products, and facilitate the regeneration of the corneal tissue. The 
incision is to be made with a broad needle in the cornea near its 
lower edge, and the aqueous humor should be allowed to flow off 
very slowly indeed. It may be necessary to repeat the operation 
several times, or, in order that its effect may be more lasting, the 
little wound may be kept patent by the occasional insertion of a 
small probe once or twice a day. 

But if the hypopyon is considerable in size, occupying perhaps 
one-third or one-half of the anterior chamber, if there is much 
iritis, or if the abscess in the cornea extends very deeply, and 

1 Ibid., vol. x. 2, 205. 

I 



SUPPURATIVE CORNEITIS. 125 

threatens to cause an extensive perforation, it is of great import- 
ance that an iridectomy should be made without loss of time; for 
the intra-ocular tension will be thus more completely diminished 
and for a longer period, than by the paracentesis. We generally 
find that the iridectomy exerts a most beneficial influence upon the 
suppuration of the cornea, and also as an antiphlogistic upon the 
inflammation of the iris. The progress of the suppuration, both in 
circumference and depth, is arrested, the deeper layers of the cornea 
do not become necrosed, and the absorption of morbid products, and 
the process of repair are hastened. Indeed, I think that an iridec- 
tomy should generally be preferred to a paracentesis, if the disease 
be at all severe and threatening perforation, more especially if the 
abscess or ulcer be of considerable size and situated in the centre of 
the cornea, for then it will leave a dense opacity behind it, and, 
after all, necessitate the formation of an artificial pupil. 

If there is a considerable hypopyon, the iridectomy should be 
made downwards, or downwards and inwards, in order that the 
lymph may escape with the aqueous humor through the large in- 
cision. If it does not do so readily, it is better to leave some of it 
in the anterior chamber than to pull and drag upon it in the en- 
deavor to remove it, for this may set up great irritation. I think 
that this is to be preferred to making the iridectomy upwards and 
then endeavoring to remove the lymph by a pair of forceps, for this 
will drag upon the lower portion of the iris, and may produce much 
irritation and increase the inflammation. 

Weber strongly recommends that the paracentesis should be made 
with a broad needle through the bottom of the abscess, so that it 
may be split across ; the gush of aqueous hum&r through the in- 
cision will carry with it more or less of the contents of the abscess, 
and thus cleanse it and favor its filling up, or Saemisch's operation 
may be performed (vide p. 133). 

In the non-inflammatory suppurative corneitis it is of great im- 
portance to keep up the patient's general health. As this affection 
is most prone to occur in delicate, weakly children, and in old and 
feeble individuals, tonics and diffusible stimulants should be freely 
administered, and the patient be placed upon a generous diet, with 
wine or malt liquor. I have been occasionally obliged to treat cases 
of this kind as hospital out-patients, and have sometimes succeeded 
in obtaining very successful results, even although the suppuration 
was already extensive and accompanied by some hypopyon and 
iritis. In such cases I have always applied atropine, warm poppy 
fomentations three or four times daily, and a compress bandage, 
and performed paracentesis (perhaps repeatedly) when the hypopyon 
had reached to more than one-fourth of the anterior chamber. I 
have at the same time prescribed full doses of quinine and steel, 
combined perhaps with ammonia or mixed acids, and ordered a 
good diet, and stimulants. 

But only absolute necessity should induce us to treat such cases 
as out-patients, as the disease is of the gravest nature, and demands 
the frequent attention of the surgeon and the constant care of a 
good nurse. 



126 DISEASES OF THE CORNEA. 



5.— ULCERS OP THE CORNEA. 

Ulcers of the cornea vary much in importance and danger accord- 
ing to their extent and their situation; in some cases their course 
is acute and rapid, in others very chronic and protracted, obstinately 
defying almost every remedy. The superficial are less important 
and dangerous than the deep-seated ulcers. In the former, we 
should not include mere abrasions of the epithelium such as may 
occur after slight injuries from foreign bodies, or from the bursting 
of the vesicle in phlyctenular corneitis. The term ulcer should, I 
think, be confined to cases in which there is a breaking down and 
elimination of the affected corneal tissue, so that there is a distinct 
loss of substance. 

When speaking of phlyctenulse and the inflammatory infiltra- 
tions of the cornea, it was mentioned that their contents often break 
down, soften, and are thrown off, giving rise to an ulcer, which may 
either remain superficial or extend somewhat deeply into the cor- 
neal tissue. But the tendency to ulceration may also show itself 
from the outset. Then there is noticed, near the centre of the mar- 
gin of the cornea, a small opacity, the edges of which are somewhat 
irregular, swollen, and of a gray color, which shades off to a lighter 
tint towards the centre, so that the latter may even seem quite trans- 
parent. The ulcer, whose epithelial covering is lost, is surrounded 
by a zone of gray and somewhat swollen cornea; it gradually 
assumes a more yellow tint, and extends in depth and circumfer- 
ence, its contents breaking down and being cast off, so that it may 
reach a considerable extent before its progress can be stopped. It 
is often accompanied by severe symptoms of irritation, great photo- 
phobia, lachrymation, and ciliary neuralgia. When the process of 
reparation sets in, we notice that the epithelial layer is gradually 
formed, this reparation commencing from the periphery. Then the 
ulcer assumes a grayer tint and is gradually filled up by new tis- 
sue, which may resemble very greatly the normal corneal tissue, 
although the intercellular substance is apt to be not quite transpa- 
rent, thus giving rise to a certain amount of opacity. Sometimes 
the process of repair is extremely slow, and many months elapse 
before the ulcer is healed. As soon as the layer of epithelium is 
regenerated the symptoms of irritation, more especially the pain and 
photophobia, rapidly subside. Bloodvessels (both venous and arte- 
rial) appear upon the cornea [Fig. 35] and run towards the ulcer, 
I hastening the process of reparation and ab- 
[Fig. 35.] sorption, and dwindling down and disappear- 

s-iT&b-t i n g when their task is done. Sometimes the 

I reparative process is incomplete, and a more 
or less deep, opaque depression or facet, of 
a somewhat cicatricial appearance, remains 
behind. 

We sometimes meet with a peculiar form 
of funnel-shaped ulcer, which shows a very 




ULCEKS OF THE CORNEA. 127 

marked tendency to extend in depth and perforate the cornea, ob- 
stinately and persistently resisting all and every kind of treatment 
until perforation has taken place, when it at once begins to heal. 

Another and very dangerous form is the crescentic ulcer, which 
commences near the edge of the cornea, and looks as if a little por- 
tion had been chipped out with the finger-nail. It shows a great 
tendency to extend more and more round the edge of the cornea 
like a trench (in which the cornea is much thinned), until it may 
even encircle the whole cornea. The vitality of the central portion 
is generally greatly impaired, and it becomes more and more opaque, 
and shrivels up until it may look like a yellow, dry, friable, or 
cheesy substance, portions of the surface of which may be thrown 
off, or it may give way and a very extensive rupture of the cornea 
take place. This crescentic ulcer is extremely dangerous and in- 
tractable, resisting often most obstinately every form of treatment. 
In some cases great advantage has been derived from syndectomy, 
either partial, if the ulcer was but of slight extent ; or complete, if 
a considerable portion of the cornea had become involved. In other 
cases I have, however, seen it do but very little good. Iridectomy 
has also been sometimes found of benefit, and should be preferred 
to paracentesis. The patient should be placed upon a very nutri- 
tious and generous diet, and tonics, together perhaps with mixed 
acids, should be administered. 

Whilst these different forms of corneal ulcer are always accom- 
panied by more or less irritation and inflammation, there are some 
forms in which the inflammatory symptoms are almost entirely ab- 
sent ; they, indeed, in their character and course may closely re- 
semble the non-inflammatory suppurative corneitis. We notice 
that the ulcer is white in color and clearly defined against the 
transparent cornea, and not surrounded by a gray, swollen zone of 
demarcation. It is accompanied by very little, if indeed any, pho- 
tophobia, lachrymation, redness, or pain; there is also more ten- 
dency to necrosis, and extension in circumference than in the other 
forms. 

One peculiar and very dangerous kind of non-inflammatory or 
indolent ulcer is that which is often met with in very aged and de- 
crepid individuals, and is generally accompanied by hypopyon. In 
character it closely resembles the non-inflammatory suppurative 
corneitis, in fact the latter very frequently passes over into this 
form of ulcer, more especially when it has been produced by an 
accident, such as a foreign body. Like it, it commences with a 
grayish-white infiltration, perhaps in the centre of the cornea, 
which soon passes over into an ulcer and extends very rapidly in 
circumference and depth, the affected tissue breaking down and 
being cast off until a large sloughing ulcer is the result. When it 
has reached a certain depth it very frequently becomes complicated 
with hypopyon, which may be due to iritis, to inflammation of 
the posterior layers of the cornea and proliferation of the epithelial 
cells, or to perforation of the ulcer and a discharge of its contents 
into the anterior chamber. One portion of the margin of the ulcer 



123 DISEASES OF THE CORNEA. 

is swollen and of a grayish-white tint, this opacity assuming some- 
times a semilunar or crescentic form, and from it small striated 
opacities run deeply into the corneal tissue. The cornea in the 
vicinity of the ulcer is generally clear and transparent or only 
faintly clouded. From the dangerous character of the disease, and 
its tendency to spread, Prof. Saemisch proposes to call it " ulcus 
serpens cornese." 1 There is a marked absence of all inflammatory 
symptoms, and in this consists its chief danger, as it leads to rapid 
and extensive sloughing of the cornea. In other cases there is 
great ciliary irritation and neuralgia, and in these there is generally 
no hypopyon (Saemisch). 

Sometimes we may observe a peculiar transparent ulcer of the 
cornea, in which both the margins and the bottom of the ulcer are 
quite translucent, and free from any opaque halo ; there is also an 
absence of vascularity. These ulcers are very intractable, and may 
persist for a long time. They may, however, heal rapidly if a suffi- 
cient degree of Vascularity can be established. 

The complications to which ulcers of the cornea may give rise 
are often very serious, and may even prove destructive to the eye. 
If the ulcer is superficial, of but slight extent, and occurs in a 
young healthy subject, it may heal perfectly, and finally leave 
hardly any, if indeed any, opacity behind ; the cornea in time 
regaining its normal transparency. Indeed, even small perforating 
ulcers which have given rise to anterior capsular cataract, may 
gradually disappear without leaving almost any trace behind them. 
I have not unfrequently met with cases of central capsular cataract 
in old persons whose cornea was apparently clear, and it was not 
until it was examined by a strong light or with the oblique illumi- 
nation, that a small opacity of the cornea could be detected just 
opposite the centre of the lens ; then, on inquiry, it was perhaps 
ascertained that the patient had as a child suffered from inflamma- 
tion of the eye. 

When the ulcer has extended very deeply into the cornea, nearly 
as far as the posterior elastic lamina (membrane of Desceruet), the 
latter may yield before the intra-ocular pressure and bulge forward, 
looking like a small transparent vesicle at the bottom of the ulcer. 
This condition has been termed hernia of the cornea or " keratocele." 
If the membrane of Descemet be very tough and elastic, it may 
protrude even beyond the level of the cornea, and thus produce a 
transparent, prominent vesicle, like a tear drop. This generally 
soon bursts, and gives rise to an ulcer, or a fistulous opening may 
remain, and prove very intractable; but it may exist for weeks or 
even months, when it gradually becomes thicker, flatter, more 
opaque, and changed into a kind of cicatricial tissue. It was 
generally supposed that the walls of this vesicle consist only of the 
membrane of Descemet pushed forward by the aqueous humor, but 
Stellwag states that they also always include some of the deepest 

' Vide a very interesting brochure, by Professor Saemisch. " Das Ulcus Come* 
Serpens," und seine Tlierapie. Bonn, Max Cohen, 1870. 



ULCERS OF THE CORNEA. 129 

layers of the cornea, traces of which may even be found at the 
sides of the vesicles, and sometimes also at the apex. 

The chief danger of the ulcers, apart from the dense opacities 
which they may leave behind, is to be found in their perforating 
the cornea, and the degree of this danger varies with the extent 
and situation of the perforation. 

If the perforation is but small, the iris will fall against it when 
the aqueous humor flows off, without protruding through it ; 
plastic lymph will be effused at the bottom of the ulcer and this 
may at once commence to heal, the iris- becoming slightly glued 
against the cornea. The aqueous humor rcaccumulates, and if the 
adhesion between the iris and cornea is but very slight, it will 
yield before the pressure of the aqueous, and the iris be liberated 
and fall back to its normal plane. The muscular action of the 
sphincter and dilatator of the pupil during the action of the pupil 
will also assist in breaking through the adhesion, but if the latter 
is at all considerable and firm, the iris will remain adherent to the 
cornea, and a more or less extensive anterior 
synechia be formed. If the perforation is 8 ^ Flg ' 30 ' 

large, as it must be if the iris falls into it and I 
protrudes through it [Fig. 36], this protrusion j 
may gain a considerable size by the collection I 
of aqueous humor behind it, which causes it 
gradually to distend and bulge more and 
more. The color of the prolapse is soon I 
changed from black to a dirty, dusky gray 
tint, and its base is surrounded by a zone of 
opaque cornea. The portion of protruding 
iris which lies against the edges of the ulcer, generally becomes 
united to the latter by an effusion of plastic lymph, the aqueous 
humor is again retained, and the anterior chamber re-established, 
with the exception of the portion in the vicinity of the prolapse, 
for here the iris is lifted away from the anterior surface of the 
lens, and a more or less considerable posterior chamber is formed. 
The pupil is distorted and dragged towards the perforation, and 
the extent of this distortion varies with the size and situation of 
the prolapse. If a portion of the pupil is included in the prolapse, 
it will be irregularly displaced and dragged towards the latter, 
and diminished in size correspondingly to the amount of the pupil 
which is involved. When the whole pupil is included, the iris 
will be tensely stretched towards the perforation ; if the latter is 
considerable in size, and the aqueous humor has gushed forth with 
much force, the lens, and even some of the vitreous humor, may be 
lost. If the prolapse is small and seen shortly after it has taken 
place, it may often be replaced under judicious treatment, and the 
ulcer perhaps heal without even an anterior synechia remaining 
behind, but if it is considerable in size the result will be much less 
favorable, for the protruding portion of iris, exposed to the action 
of external irritants, e.g., the air, movements of the lids, etc., be- 
comes inflamed and covered by a thin grayish-white layer of exu- 
9 




After Miller.] 



130 DISEASES OF THE. CORNEA. 

dation, which gradually becomes thicker and more organized, and 
assumes a 'cicatricial texture. Now, if this cicatricial covering and 
the adhesions of the iris to the edges of the ulcer are not sufficiently 
strong to withstand the intra-ocular pressure, the prolapse will 
gradually increase in size, and the surrounding portions of the 
cornea will also bulge more and more, until an extensive staphy- 
loma may be produced. If the cornea is perforated at several 
points, through which small portions of iris protrude, it is termed 
" Staphyloma racemosum." 

If the perforation is very small, and situated at or near the centre 
of the cornea, capsular cataract may be produced in the manner 
already described. Again, the sudden escape of the aqueous humor, 
and falling forward of the lens, may cause a rupture of the capsule, 
and thus give rise to lenticular cataract. 

With regard to the treatment of ulcers of the cornea, we must 
be chiefly guided by the amount of inflammation which is present. 
Whilst we endeavor to check an undue degree of inflammation, we 
must be on our guard not to subdue it too much, as this would 
favor the tendency to necrosis, and protract the process of repara- 
tion. In the progressive stage of an acute inflammatory ulcer, the 
patient should be kept in a somewhat darkened, but well-ventilated 
room, and be guarded against the effects of bright light, cold wind, 
and other external irritants. It may be necessary to administer a 
brisk purgative and saline diuretics, together with a light, non- 
stimulating diet, if there are marked inflammatory symptoms and 
the patient is of a strong, plethoric habit. But we must be upon 
our guard not to prescribe this kind of treatment in all cases, for 
very frequently ulcers of the cornea occur in persons of delicate, 
feeble health, and theu it would prove injudicious and injurious, 
for it would increase the tendency to necrosis, and retard the filling 
up of the ulcer. In such cases, the patient should be placed on 
tonics, and a -very nutritious diet. When the process of repair has 
set in, he should be permitted to get into the open air, indeed this 
is especially indicated if the disease shows a tendency to become 
indolent and chronic. Much benefit is then experienced from out- 
of-door exercise, and a residence in the country or at the sea-side. 

The object of our local treatment must be to endeavor to dimin- 
ish marked symptoms of inflammatory irritation, to stop the pro- 
gress of the ulcer, and to hasten its repair and the absorption of the 
morbid products. If there is much injection^ photophobia, lachry- 
mation, and ciliary neuralgia, atropine should be dropped into the 
eye, the compound belladonna ointment should be rubbed over the 
forehead, and perhaps a blister applied behind the ear. If the 
pain in and around the eye is very great, and especially if the latter 
is very tender to the touch, two or three leeches should be applied 
to the temple. Much relief will also be experienced from the sub- ■ 
cutaneous injection of morphia. A great amount of mischief is but 
too often caused by the use of strong caustic or astringent lotions, 
during the acute, progressive stage of the ulceration. Not only do 
they greatly augment the irritation, but they increase the tendency, 



ULCERS OF T.HE CORNEA. 131 

to necrosis and extension of the ulcer. It is only in the chronic, 
torpid ulcer which has already become covered by epithelium, that 
caustics are at all applicable, and even then they must be used with 
great caution and circumspection. In the chronic, indolent, non- 
inflammatory ulcer we must apply atropine, a compress bandage, 
and above all, warm fomentations, in order to excite a certain 
degree of inflammatory swelling ; or the yellow oxide of mercury 
ointment may be employed, for this remedy hastens the process of 
absorption and tends to prevent relapses. The patient's health 
must be invigorated by tonics, a generous diet, and stimulants ; in- 
deed the same line of local and general treatmeut must be adopted 
as in non-inflammatory suppurative corneitis. We must never 
forget to apply a compress bandage over the eye, in order not only 
to guard it against external irritants, but to support the thinned 
ulcerated portion of the cornea against the intra-ocular pressure, 
and to prevent the constant movements of the eyelids, which greatly 
impede the formation of an epithelial- covering over the ulcer; 
which, as we have seen, forms the commencement of the retrogres- 
sive and reparative stage. If the photophobia is very intense and 
obstinate, and the firm pressure of the lids prevents the process of 
reparation in the ulcer, much benefit is experienced from the di- 
vision of the outer canthus, as recommended by Mr. Carter, 1 which 
speedily relieves the photophobia and greatly accelerates the heal- 
ing of the ulcer. 

In all ulcers of the cornea, but more especially in those which 
extend deeply into its substance, the process of repair is greatly 
retarded by the high amount of intra-ocular pressure, which the 
thinned portion of the cornea at the bottom of the ulcer has to bear. 
In consequence of this, the latter is very apt either to give way 
completely, and to perforate ; or else it yields somewhat before the 
intra-ocular pressure, bulges forwards, sloughs, and is partly thrown 
off, and thus the process of repair is much impeded. Now we 
possess three principal means of diminishing the intra-ocular pres- 
sure, viz., atropine, paracentesis, and iridectomy. The beneficial 
action of atropine, both as a direct sedative and in reducing the 
intra-ocular tension, has been already explained. 

If the ulcer has extended so deeply into the substance of the cor- 
nea as to threaten perforation, no time should be lost in performing 
paracentesis at the bottom of the ulcer ; by so doing, we shall be 
able to limit the perforation to a very small extent; for if we per- 
mit the spontaneous perforation of the ulcer, we find that before 
this occurs the bottom of the ulcer extends somewhat in circum- 
ference, and thus a considerable, ragged opening may result, and 
the latter will certainly be much larger than if it had simply been 
made with a fine needle. Moreover, the escape of the aqueous 
humor will, in the former case, be more sudden and forcible, which 
is apt to produce considerable hyperemia ex vacuo of the deeper 
tunics of the eyeball ; prolapse of the iris, which may lead to sup- 

1 "Practitioner," January, 1869. 



132 



DISEASES OP THE CORNEA. 



purative iritis or irido-choroiditis; or rupture of the capsule, arid 
consequent cataract ; or again, the suspensory ligament of the lens 
may be torn, and the lens partially dislocated. The paracentesis 
should not be postponed until the deepest layers of the cornea are 
implicated, for we then run the risk of a large spontaneous perfora- 
tion occurring before we have time to interfere. The puncture 
should be made with a fine needle at the deepest portion of the 
ulcer, and the aqueous humor allowed to flow oft' as gently as pos- 
sible. The iris will gradually move forward, and come in contact 
with the back of the cornea ; a thin layer of lymph will be effused 
at the bottom of the ulcer, under which the regeneration of the 
corneal tissue will take place, the iris being generally more or less 
glued to the perforation by the effusion of lymph. As soon as the 
opening is stopped by this plug of lymph, the aqueous humor will 
re-accumulate, and if the adhesion between the iris and cornea is 
but slight, it will readily yield to, and be torn away by, the force 
of the aqueous humor and the action of the muscles of the iris. 
But if the layer of lymph at the bottom of the ulcer is thin and 
weak, the force of the intra-ocular pressure may rupture it, or may 
cause it to bulge forward, and thus necessitate a repetition of the 
paracentesis. The latter should also be repeated, perhaps even 
several times, if we notice that the process of repair becomes 
arrested, and that the ulcer again shows a tendency to increase in 
depth. After the operation, a compress bandage should be applied. 
If the ulcer is extensive, and if hypopyon or iritis co-exist, the 
puncture should be made with a broad needle at the edge of the 
cornea [Fig. 37], or an iridectomy should be substituted. The indi- 
cations which should guide 



[Fig. 37. 




us m selecting between 
these two operations have 
already been considered in 
the article upon suppura- 
tive corneitis. 

In the indolent hypopyon- 
ulcer (ulcus serpens of Sae- 
misch), described at p. 127, 
a vast number of remedies 
have been tried, of which 
the most successful have 
been warm fomentations, 
paracentesis, and iridec- 
tomy, together with tonics 
and a generous diet. It 
must, however, be confessed 
that such success has been but. limited, more especially when the 
ulcer was extensive, rapidly spreading, and accompanied by a con- 
siderable hypopyon. Saemisch has lately devised the following 
operation for the purpose of dividing the base of the ulcer and 
maintaining a diminution of the intra-ocular tension for some 
length of time, so that the progress of the disease may be arrested, 



After Ericbsen. 



ULCERS OF THE CORNEA. 133 

and the process of repair accelerated. His results have been very 
favorable, for out of 35 cases in which the operation was performed, 
the progress of the affection was at once arrested in 34. The 
amount of sight which was saved, varied of course according to 
the circumstances of the case. The eyelids being kept apart with 
the stop speculum, and the eyeball fixed with a pair of forceps, a 
puncture is made with Von Graefe's narrow cataract knife at the 
temporal side of the ulcer in the healthy portion of cornea, about 
1 mm. from the margin of the ulcer. The point of the knife having 
entered the anterior chamber, the blade is to be carried through 
the chamber behind the bottom of the ulcer (towards the bottom 
of which the edge is to be turned), and the counter-puncture made 
at a point corresponding to the puncture, and likewise situated in 
the healthy cornea, slightly beyond the margin of the ulcer. The 
fixing forceps are now laid aside, and then, with a slight sawing 
movement, the knife is to cut its way out through the ulcer, the 
blade being several times turned a little on its axis, so that the 
aqueous humor may flow off very gently beside the blade. The 
last portion of the cornea should be divided as slowly and gently 
as possible. If there is any hypopyon, it generally escapes through 
the incision. A light compress is to be applied, and within an 
hour or two the wound is generally already closed, and then atro- 
pine should be used. The wound is to be opened twice daily for 
the first few days with a probe, or still better with Weber's beak- 
pointed canaliculus knife, the blunt point of which is to be inserted 
between the lips of the incision ; but care must be taken that this 
is delicately done, so that the aqueous humor flows off very gently. 
The wound must be re-opened every day until the process of repair 
has become thoroughly established, which is known by the fact 
that the opaque and swollen margin becomes narrower and nar- 
rower, breaks up into punctated or faintly striated opacities, until 
it finally disappears altogether, and then the incision may be 
allowed to close. This generally occurs at about the second or 
third week. When the symptoms of irritation have subsided, the 
red precipitate ointment may be applied, to accelerate the healing 
of the ulcer and the absorption of the opacity. 

In cases of obstinate ulceration of the cornea, confined chiefly or 
entirely to one portion of the latter, much benefit is sometimes 
derived from syndectomy of the corresponding segment of the scle- 
rotic ; so that the blood supply of the affected portion of the cornea 
may be more or less cut off. In obstinate, chronic, vascular ulcers 
of the cornea, which have long resisted every form of treatment, 
and show a great tendency to recur, the insertion of a seton at the 
temple often renders the most marked and striking benefit, the 
disease being rapidly cured, and the relapses prevented, if the seton 
is worn for some time after the corneal ulcer is healed. 

We are especially indebted to Mr. Gritchett for introducing this 
mode of treatment 1 in certain cases of chronic vascular ulcers of the 

1 Mr. Spencer Watson has also published some able papers upon this subject in 
the " R L. O. H. Rep." and in the " Medical Minor." 



134 DISEASES OF THE CORNEA. 

cornea, which are particularly characterized by their protracted 
course, their great tendency to recur, and the obstinacy with which 
they resist all ordinary methods of treatment. Mr. Critchett has 
favored me with the following description of the manner in which 
the seton is to be applied : — 

" I generally use rather stout silk or fine twine, such as a large 
suture'needle will carry. I select a spot near the temporal region 
under the hair, so as to avoid as far as possible a visible scar. Care 
is required not to wound the temporal artery ; this may generally 
be avoided by drawing the skin well away from the temporal fascia, 
holding it firmly by the hair. The needle is thus passed through 
at a level, anterior to the artery ; about an inch is usually included, 
and a loose loop is formed, which may be placed behind the ear ; 
it requires to be dressed and moved daily ; it usually continues to 
discharge for two or three months, and then either cuts its way 
through, or dries up. In severe and obstinate cases, where it is 
necessary, it may be renewed, selecting a spot near to the previous 
scar. I have sometimes found it desirable to continue the influence 
of a seton for 12 months. There are certain inconveniences that 
occasionally arise to which I may briefly allude. It will sometimes 
happen that in spite of every care and precaution a branch of the 
temporal artery is pricked by the point of the needle as it traverses 
the skin ; this accident is at once recognized by the rapid outflow 
of arterial blood from one or both openings, through which the silk 
passes. In the event of such an accident, it is better at once to 
remove the silk, and then moderate pressure checks the bleeding, 
and in a few days a neighboring spot may be selected for the rein- 
troduction of the silk ; but if this precaution be not taken, and if 
an effort be made to retain the seton in spite of the hemorrhage, 
there is a great liability to secondary bleeding, to extravasation of 
blood beneath the scalp, burrowing abscesses, and other untoward 
casualties, and in one instance I observed the formation of a small 
traumatic aneurism. In certain exceptional cases the introduction 
of the seton is followed by considerable swelling of the surrounding 
parts, with a tendency to erysipelas, and suppurative inflammation 
cannot be established. As soon as these symptoms show themselves 
the silk should be removed." 

If an ulcer is situated at or near the centre of the cornea, and 
perforation appears inevitable, the pupil must be kept widely dilated 
with atropine, in order that, when the cornea gives way and the 
aqueous humor escapes, the edge of the pupil may riot be involved 
in the perforation. On the other hand, if the ulcer is situated near 
the margin of the cornea, the reverse is indicated, and the pupil 
should be allowed to remain undilated, or even stimulated to ex- 
treme contraction, by the application of the extract of the Calabar 
bean, in order to remove the edge of the pupil as far as possible 
from the situation of the threatening perforation. Either of these 
remedies is also indicated when a slight adhesion exists between 
the cornea and iris (anterior synechia), for, by the strong action of 
the muscles of the iris which they produce, the adhesion may be 



ULCERS OF THE COESEA. 135 

forcibly torn through. Mr. Pridgin Teale informs me that he has 
often derived much benefit from dividing anterior synechise. This 
is done both with the view of causing a diminution of the corneal 
opacity, at the site of adhesion, and of releasing the iris from its 
drag. 

If a slight prolapse has occurred, we must at once attempt to 
replace it by pressing it gently back with a spatula or probe, or we 
may endeavor to cause it to recede by widely dilating the pupil by 
atropine. A firm compress should be applied in all cases of prolapse, 
for it will favor the consolidation of the wound by the formation of 
a layer of lymph over the prolapse, and will prevent the latter from 
yielding to the intra-ocular pressure and increasing in size. Thfc 
protruding portion of iris should also be pricked with a fine needle, 
and the aqueous humor be allowed to escape ; for this will cause the 
prolapse to shrink and gradually dwindle down. This operation 
may be repeated several times, and generally with the best results ; 
but if the prolapse is large and prominent, it should be first pricked 
with the needle, and then, when the escape of the aqueous humor 
has caused it to collapse, it should be seized with the iridectomy 
forceps, and snipped off with a pair of curved scissors quite close to 
the cornea, a firm compress being at once applied. The same treat- 
ment is to be pursued in staphyloma iridis. 

Some surgeons recommend that the prolapse should be touched 
with a point of nitrate of silver, or with a little vinum opii ; but 
this is apt to set up great irritation and may even produce severe 
iritis. If it be done at all, a weak solution of nitrate of silver 
should be lightly applied to the apex of the prolapse, with a fine 
camel's hair brush. In a considerable and obstinate prolapse, much 
benefit is generally derived from making a large iridectomy in an 
opposite direction, for this will often cause the prolapse to recede 
and flatten. This operation is likewise indicated when the pupil 
is partly or wholly implicated in the prolapse or anterior synechia ; 
also, when there is a partial staphyloma, and, above all, when this 
is accompanied by an increase in the intra-ocular tension. For, as 
has been pointed out by Von Graefe, in cases of partial or complete 
staphyloma, or of leucoma prominens, the degree of blindness is 
frequently quite disproportionate to the optical condition. In such 
cases, there is often contraction of the visual field, eccentric fixation, 
increase in the intra-ocular tension, and excavation of the optic 
nerve. "When glaucomatous symptoms supervene upon partial sta- 
phyloma or lucoma prominens, we find the cornea becomes at this 
point markedly prominent, even after it has already become thick- 
ened and consolidated. 

Fistula of the cornea often proves very obstinate and intractable, 
and even dangerous to the eye, leading perhaps finally to irido- 
choroiditis and atrophy of the eyeball. A fistulous opening of the 
cornea may result in cousequence of a small perforating ulcer, or 
from a wound of the cornea, with or without injury to the lens. 
The fistulous opening may become temporarily closed, so that the 
aqueous humor re-accumulates, but after a short interval it again 



136 DISEASES OF THE CORNEA. 

gives way, the aqueous flows off, and the anterior chamber is ob- 
literated. This may occur over and over again. "When fistula of 
the cornea exists, the eye remains irritable and injected, the intra- 
ocular tension is greatly diminished, the anterior chamber oblite- 
rated, and a small drop of fluid may be noticed exuding through 
the aperture in the cornea. Various modes of treatment have 
been advocated. At the outset, a firm compress bandage should 
be applied, as well as a strong solution of atropine, and if this fails 
to heal the fistula, the latter may be touched with the point of a 
fine camel's hair brush dipped in a weak solution of nitrate of 
silver, this being repeated several times at an interval of a day or 
two. The disadvantage of this mode of treatment is, however, 
that it often produces an indelible cicatrix. An iridectomy fre- 
quently proves of more, service. "Wecker 1 considers that the fistula 
is due to an eversion of the membrane of Descemet at this point, 
and has therefore devised the following treatment. He introduces 
into the opening a very fine, smooth-pointed, straight pair of for- 
ceps, and, seizing the wall of the fistulous track, bruises its lining, 
and thus denudes the corneal tissue. This having been done at 
several points, atropine and a compress bandage must be applied. 
Great care and delicacy are required not to rupture the capsule 
with the point of the forceps. He has thus cured a case of fistula 
of the cornea, which had resisted for ten months different modes 
of treatment. Zehender 2 has found the prolonged use of the extract 
of Calabar bean of great service in curing a corneal fistula. 



6.— DIFFUSE CORNEITIS (PARENCHYMATOUS, 
INTERSTITIAL, SYPHILITIC). 

In this disease we may also distinguish two principal forms. 
The one is accompanied by marked symptoms of inflammation, 
and is hence called " diffuse vascular corneitis." In the other, or 
" non-vascular" form, these symptoms are entirely absent. 

1. In the vascular diffuse corneitis we notice, together with a 
certain varying degree of conjunctival and subconjunctival injection, 
a zone of vessels passing from the margin of the cornea more or 
less towards the centre, where they terminate in a sharply defined 
line. They are not situated on the surface of the cornea, as those 
in pannus, but enter deeply into its substance. They consist in 
part of vessels derived from the junction of the conjunctival and 
subconjunctival vessels near the margin of the cornea, and in part 
also of branches coming from the bloodvessels of the ciliary body. 
Sometimes the vascularity at the edge of the cornea is so great, 
that it looks like a bright red zone of extravasated blood. Soon 
there is noticed at one or more points, a slight opacity of the cornea, 
which generally commences at the margin where its density is 
greatest, and gradually shades off towards the centre into trans- 

1 " Annales d'Oculistique," yol. 56, 305. « " Kl. Monatsbl." 1868, 35. 



DIFFUSE OORNEITIS. 137 

parent cornea. Sometimes, however, the opacity begins at the 
centre, whence it slowly extends towards the periphery. The 
cloudiness gradually increases in extent and thickness, until the 
whole surface of the cornea may become diffusely opaque. The 
density and color of the opacity vary a good deal. Thus, it may 
be but thin, and of a grayish-white color, having very much the 
appearance of frosted glass, or it may be thicker and of a yellowish 
creamy tint, more especially in the centre of the cornea. Indeed, 
at this point we not unfrequently see a large circular patch of a 
pale yellow color, which is evidently deeply seated in the substance 
of the cornea. This central patch may gain a considerable size, 
even of two or three lines in diameter. Sometimes several such 
denser patches may be noticed at different points. The epithelial 
layer at first retains its normal smoothness, but after a time it be- 
comes somewhat rough and thickened, as if it had been lightly 
pricked by a pin, or a fine powder had been strewn over it. The 
disease shows very little tendency to ulceration or to purulent ne- 
crosis, unless it has been very injudiciously treated by caustics or 
strong astringent collyria. But the whole surface of the cornea 
may be swollen and become somewhat prominent, yielding here 
and there to the intra-ocular pressure and bulging forward. Gener- 
ally these prominences disappear with the infiltration, but if they 
have been considerable, they may leave behind some impairment 
of the true curvature of the cornea. The amount of inflammation 
and ciliary irritation vary very much. Sometimes, there is very 
considerable and obstinately persistent photophobia, together with 
lachrymation and a certain degree of ciliary neuralgia. In other 
cases, these symptoms never assume any particular prominence. 
The sight is always greatly impaired, so that the patient can hardly 
see a band moving, which is due to the diffuse character of the 
opacity, for it is as if he were looking through a piece of ground 
glass. If both eyes become affected, which is generally the case, 
the effect of this total loss of sight is most depressing, and demands 
the greatest confidence in the surgeon to prevent the patient from 
seeking other and perhaps injudicious advice. For the disease 
runs a most slow and protracted course ; months and months elapse 
before any, even slight, improvement begins to show itself, and 
during all this time no treatment appears of any special service. 
We can but let the disease run its course, and endeavor to guide 
it in its progress. It may take from six to eight weeks until it 
has reached its acme ; the cornea being then, perhaps, almost covered 
with closely crowded bloodvessels, which reach nearly up. to its 
very centre, where is seen a thick yellow infiltration. The red 
appearance of the cornea is often increased b}' small extravasations 
of blood, caused by the giving way of some of the vessels. The 
disease may now remain stationary for a few weeks, and then the 
process of reparation sets in. The vascularity diminishes ; the 
vessels are less closely arranged at the edge of the cornea, and show 
more or less considerable gaps between them ; and the infiltration 
becomes thinner and lighter in color, gradually disappearing more 



138 DISEASES OF THE CORNEA. 

and more from the periphery towards the centre, which is the last 
to clear up. 

The prognosis of the disease is, on the whole, favorable, for, 
although it runs a most protracted course, which may extend over 
many months, and although the opacity of the cornea may be so 
dense as to prevent the patient from even counting fingers, there 
is no tendency to ulceration of the cornea, and the opacity gradu- 
ally disappears until there is finally perhaps only a slight cloudiness 
left. Both eyes are generally affected, and this renders the disease 
of course the more harassing and alarming to the patient, who may 
thus remain for many weeks almost totally blind. Iritis is a fre- 
quent accompaniment of the inflammation of the cornea, and may 
be quite unsuspected during the progress of the case, as the iris is 
hidden from view by the opacity of the cornea ; and it is only 
when the latter becomes clearer that the iris is found somewhat 
discolored, and the pupil irregular and adherent. But a still graver 
and more dangerous complication is inflammation of the ciliary 
body, which is especially apt to occur if the case has been inju- 
diciously treated, and caustic or strong astringent collyria have 
been applied. We must suspect this complication, if the symptoms 
of inflammatory irritation are greatly increased in intensity, if the 
vascularity, photophobia, lachrymation, and ciliary neuralgia are 
severe, if the sight is rapidly diminished, and the field of vision 
markedly contracted, and if the eye at the region of the ciliary 
body is extremely sensitive to the touch. 

Diffuse corneitis is especially apt to occur between the ages of 
five and twenty, but it may be met with up to thirty-five or forty. 
It generally occurs in persons in a feeble, delicate state of health, 
which maybe due to numerous causes, such as want and privation, 
very hard and fatiguing work, more especially in a confined or viti- 
ated atmosphere ; and it is often met with in persons affected with 
a scrofulous diathesis, or with inherited syphilis. I cannot at all 
agree with the view that diffuse corneitis is always due to inhe- 
rited syphilis, for although I have often seen it associated with the 
latter, yet in many cases not the slightest trace of a syphilitic taint 
could be ascertained, and there was a marked and complete absence 
of the peculiar syphilitic features and the notched teeth. Indeed, 
I think that we are often too apt hastily to jump to the conclusion 
' that hereditary syphilis exists, when on a more careful and search- 
ing examination into some of these histories, it would be found 
that the miscarriages, early deaths of the children, etc., were due 
to perfectly natural causes, and quite independent of any syphilitic 
taint. I may of course be met with the constantly recurring argu- 
ment that it is impossible to get at the truth of the history, but I 
think that we are justified in giving the patient and his parents 
the benefit of the doubt, if no reliable proof of the presence of 
inherited syphilis can be made out. For this reason, I must com- 
pletely disagree with those authors who term this disease " syphi- 
litic corneitis." For, as I have already stated, it is frequently met 
with in persons, in whom not the slightest trace of a syphilitic 



DIFFUSE COKNEITIS. 139 

taint can be detected. Whilst combating some of these views, I 
must, however, seize this opportunity to express my admiration 
for the very important and interesting researches of Mr. Jonathan 
Hutchinson, 1 into the frequent connection between inherited 
syphilis and many of the diseases of the eye, a discovery which 
has proved of great importance and use in the treatment of these 
affections. 

[If the corneitis occur in connection with hereditary syphilis, the 
existence of the latter may generally be diagnosticated, as pointed 
out by Mr. Hutchinson, by certain peculiarities presented by the 
permanent teeth, especially by the upper central incisors, which are 
the most reliable for purposes of diagnosis. The characteristic mal- 
formation of the upper central incisors consists in a dwarfing of 
the tooth, which is usually both narrow and short, and in the 
atrophy of its middle lobe. This atrophy leaves a single"" broad 
notch (vertical) in the edge of the tooth. This notching is usually 
symmetrical, as shown in Fig. 38. It may vary much in degree in 
different cases. Sometimes the teeth diverge, and at others they 
slant towards each other. The appended wood-cut, Fig. 39, affords 

Fig. 38. Fig. 39. 





a good illustration of the deformity. In the majority of cases the 
condition of the teeth is sufficient only to excite suspicion, and 
not to decide the question, although in a marked case of malfor- 
mation Mr. Hutchinson states that he would feel " no hesitation in 
pronouncing the possessor of the teeth to be the subject of inherited 
syphilis, even in the absence of other testimony." 2 In a considerable 
number of cases of hereditary syphilis, the teeth show no deviation 
whatever from the normal standard, and in such the diagnosis 
must be guided by other and well-known symptoms.] 

Mr. Brudenell Carter points out that the absence of syphilis in 
the parents does not necessarily preclude its existence in children, 
as the taint may have been introduced by vaccination. 3 

■In the treatment of this disease, we must be chiefly contented with 
guarding the eye against all noxious influences, such as bright light, 
wind, draughts, etc., and must endeavor to prevent the inflamma- 
tory symptoms from gaining an undue prominence. Unfortunately 
we' do not at present know of any means of checking the pro- 
gress and development of the disease, or of curtailing its protracted 
course. The use of caustics or astringent collyria must be most 
carefully avoided, as they only tend to increase the inflammatory 

1 Vide Mr. Hutchinson's admirable work, " Syphilitic Diseases of the Eye and 
Ear." 
1 "Reynolds' System of Medicine," vol. i. page 317. 
3 "Lancet," 1868; 1, 765. 



140 DISEASES OF THE CORNEA. 

irritation and to produce complications, such as ulcers of the cornea, 
or inflammation of the iris or ciliary body. At the outset, atro- 
pine should always be applied, although when the cornea becomes 
diffusely clouded, it is but of little use, as it is not absorbed, and it 
is apt to increase the inflammation if it be too long continued. But 
when the cornea begins to clear, atropine or the belladonna collyrium 
should be again applied. Local depletion and very antiphlogistic 
treatment are not well borne, on account of the weakly and feeble 
health of the patient. Moreover, they tend to impede the forma- 
tion of bloodvessels on the cornea, and to protract the course of the 
disease. B ut if symptoms of cyclitis make their appearance, leeches 
should be applied to the temple, and paracentesis should be per- 
formed ; and if the sight deteriorates greatly, the field becomes 
contracted, and especially if the intra-ocular tension increases, an 
iridectomy should be made at once. When the cornea is begin- 
ning to clear up, the absorption of the morbid products may be 
hastened by applying slight irritants. The best to commence with 
is the insufflation of calomel, which should be employed once daily. 
If the eye bears this well, without becoming too much irritated, 
the yellow precipitate ointment should be substituted for it. At 
first, I generally employ it of about the strength of two grains to 
.the drachm, and use but a very small quantity. If it excites much 
irritation, I apply a still weaker ointment, or postpone its use for a 
few days. I have found it by far the best remedy for accelerating 
the absorption of opacities of the cornea. A collyrium of iodide of 
potassium (gr. ij ad Ij) is also serviceable for this purpose. In 
very obstinate cases of diffuse corneitis I have also occasionally 
found much benefit from the application of a seton to the temple. 
Hasner has practised paracentesis. 

In some cases iridectomy proves beneficial not only in accelerating 
the cure, but also in the early stage sometimes arresting the pro- 
gress of the disease. Mr. Pridgen Teale informs me that he has 
practised it with success in cases in which the progress of the disease 
was rapid and unchecked by other remedies, and in which there 
had been a diminution of the eye tension before the operation. 

It is of great importance to attend to the general health of the 
patients, as they are as a rule of a feeble cachectic habit. Tonics, 
especially the syrup of the iodide of iron, quinine, or the citrate of 
quinine and steel, should be administered. Cod-liver oil, with or 
without quinine or steel, is also of much benefit. If a syphilitic 
taint is suspected, the iodide and bromide of potassium in combi- 
nation with the bichloride of mercury and cinchona, may be given 
with much advantage. The diet should be nutritious and easily 
digestible. Meat may be allowed two or three times daily, and 
wine and malt liquor may be freely administered. In fact every- 
thing should be done to strengthen the patient. In hospital prac- 
tice, I have often been obliged to take such patients into the house for 
many months, in order that they might have more attention, and 
a more generous diet than they would have obtamed at home. 
When the acute stage is past, and the cornea is beginning to clear, 



DIFFUSE CORNEITIS. 141 

the patient should, if possible, be sent into the country, or still 
better, to the sea side, and enjoy a great deal of out-of-door exercise. 
The obstinate photophobia and chronic irritability of the eye, which 
often prove so troublesome, yield sometimes most rapidly to change 
of air. 

2. In the non-vascular diffuse corneitis, we notice that a small cloud 
appears in the centre of the cornea, unaccompanied by any but the 
slightest symptoms of irritation, and there is only a very faint 
rosy injection around the cornea, but not extending on to it. In 
the course of ten or fourteen days the opacity extends over the 
whole surface of the cornea, giving it the appearance of ground 
glass, or of a mirror that has been lightly breathed upon. The 
symptoms of irritation, especially the photophobia, may now in- 
crease somewhat, but the vascularity remains slight. The vessels 
never become very numerous or closely crowded together, as is the 
case in the vascular form ; but individual vessels straggle on to- 
wards the infiltration, and do not terminate uniformly in a defined 
line. The opacity gradually becomes somewhat more dense and 
yellow towards the centre, and then, after a time, clears up at the 
periphery, and the infiltration slowly disappears in a centripetal 
direction. The course of this form is also extremely protracted, 
and many months may elapse until the cornea regains its transpa- 
rency. The prognosis is still more favorable than in the vascular 
form, for there is far less tendency to complications with inflam- 
mation of the iris or ciliary body, or to ulceration of the cornea ; 
although the latter may be produced if strong caustics or astrin- 
gents be employed. 

The causes are the same as in the vascular form. If thei'e is any 
marked irritability of the eye, this should be treated by atropine, 
cold compresses, blisters, etc. But in the majority of the cases just 
the reverse obtains, the progress of the affection languishes and 
becomes torpid, and there is a complete absence of all symptoms of 
inflammatory irritation. In such cases it is advisable to apply a 
slight irritant, more especially the yellow oxide of mercury oint- 
ment, every day for a few days. This will excite a little irritation, 
the central portion of the infiltration will become somewhat more 
thick and yellow, and the progress of the disease will be accele- 
rated. It has often been noticed that a certain amount of conjunc- 
tivitis is very favorable. Thus, if the patient suffering from this 
form of corneitis, by accident, contracts catarrhal ophthalmia, the 
progress of the affection of the cornea will be greatly hastened, and 
an infiltration disappear in a few weeks, which would otherwise 
have taken many months before it had become absorbed. This 
fact led Von Graefe to employ warm fomentations in these cases, 
in order to excite a certain degree of inflammatory swelling of the 
conjunctiva. They are indicated if the vascularity and irritation 
are but very slight, and the progress of the disease extremely pro- 
tracted and sluggish. They must be employed with care and cir- 
cumspection, so that they may not excite too much inflammation 



142 



DISEASES OF THE CORNEA. 



of the conjunctiva, which would retard instead of hastening the 
absorption of the infiltration, and perhaps leave it incomplete. 



1.— OPACITIES OF THE CORNEA. 

These vary much in situation, extent, and thickness. If they are 
quite superficial and thin, looking like a faint, grayish-blue cloud, 
they are termed nebulae. If the opacity is of a denser, white, pearly, 
tendinous character, and situated more deeply in the substance of 
the cornea, it is called an albugo or leucoma. 

A temporary diffuse opacity of the cornea may be produced by 
sudden increase of the intra-ocular pressure, as in certain forms of 
glaucoma, etc. This opacity is probably due in part to a displace- 
ment of some of the corneal elements, and also, perhaps, to a dis- 
turbance of the nutrition of the cornea from the compression of the 
nerves. 

"We meet with a very superficial opacity of the cornea, which is 
due to changes in the epithelial layer. Here and there the epithe- 
lial cells become thickened, aggregated together, and opaque, their 
contents having perhaps undergone fatty degeneration. These 
opacities are of a faint gray, or bluish-gray color, with an irregular 
margin. In their centre, the reflection of an object, for instance 
the bars of a window, will be found .indistinct, or more or less dis- 
torted. Generally the opacities are easily observable. They may, 
however, be so slight as to escape detection, except with the oblique 
illumination, when they become very evident. They are chiefly 
met with as the result of the superficial forms of corneitis, especially 
pannus due to distichiasis or granular lids, and also of the super- 
ficial ulcers of the cornea. 

The deeper opacities, which are situated in the substance of the 
cornea itself, may be confined to a certain portion of it (partial 

leucoma) [Fig. 40], or extend over 
its whole surface (total leucoma). 
The cloudiness may either be of a 
uniform grayish-blue, or grayish- 
white color, or may be made up 
of several opaque, white patches 
or spots of varying extent and 
shape. The outline of these opa- 
cities is irregular and not sharply 
L defined, being shaded gradually 

' W S Sm s S SK ' off into the normally transparent 

cornea. Their thickness and color 
After Dairympie*.] also vary much, from a grayish- 

blue to a yellowish-white and 
densely opaque tint. The epithelial layer is often irregular and 
punctated, as if a fine powder had been dusted over it, and this 
causes a distortion of the reflected image. Or, again, the opacities 




OPACITIES OP THE CORNEA. 143 

may look like little opaque, chalky nodules strewn about on different 
portions of the cornea (generally near its surface), and are the re- 
mains of phlyctenulse. 

Tine punctated opacities are also met with on the posterior surface 
of the cornea. They are generally arranged in the form of a pyramid, 
with its base downwards, and are chiefly due to a precipitation of 
lymph on the posterior wall of the cornea, but also perhaps to in- 
flammatory changes in the posterior epithelial layer. These peculiar 
opacities are observed in serous iritis (sometimes termed aquo-cap- 
sulitis, corneitis punctata, etc.), and also in inflammations of the 
deeper tunics of the eyeball, and sympathetic ophthalmia. In the 
latter cases, similar punctated opacities may also occur on the ante- 
rior surface of the cornea. The different opacities which we have 
mentioned, are chiefly due to ^inflammatory changes in the corneal 
and epithelial cells, and are capable of undergoing almost complete 
absorption, so that they may hardly leave a trace behind them. It 
is necessary to distinguish from them another form of opacity, 
which is dependent upon permanent change, often of a tendinous 
or cicatricial nature, and hence does not undergo absorption, but 
remains indelible. These opacities are more regular and sharply 
defined in their outline, and have a more uniform, tendinous, glist- 
ening-white or chalky appearance, having, perhaps, a deposit of 
fatty or earthy matter in the centre. The epithelial layer is smooth 
and not irregular. These cicatrices vary in extent and shape, in 
accordance with the size and depth of the original ulcer ; they do 
not, however, correspond exactly to it, because a portion of the 
latter is very frequently filled up by transparent corneal tissue. 
These cicatricial opacities occur very frequently together with 
those due to inflammatory changes, so that we have the two forms 
existing together. The cicatrix, instead of being sharply defined, 
is then surrounded by a more or less wide, opaque areola of inflam- 
matory infiltration. The latter may in time become completely 
absorbed and transparent, and leave only the cicatricial opacity, 
which will, of course, be now considerably less in size than the 
original leucoma. 

In cases of perforating ulcer of the cornea, accompanied with 
anterior synechia, the cicatrix to which the iris remains attached 
is termed leucoma adherens. If it be situated near the centre of the 
cornea, a portion of the pupil will be included in it, leaving, per- 
haps, the other part of the pupil free, and opposite a transparent 
portion of the cornea. 

A peculiar superficial opacity of the cornea is sometimes met 
with, which is due to calcareous deposits (consisting of phosphate 
and carbonate of lime) in the anterior elastic lamina. These 
opacities are of a mottled brownish hue, with an indistinct margin, 
which shades off, more or less abruptly, into the healthy cornea. 
Their course is very protracted, and they are apt simultaneously 
to affect both eyes. Two very interesting cases of this peculiar 
opacity, which occurred about the same time, have been described 



144 DISEASES OF THE CORNEA. 

by Mr. Dixon 1 and Mr. Bowman. 2 In each of these cases a portion 
of the opacity opposite the pupil was scraped off with a scalpel, 
and was found to consist of hard gritty matter, situated just be- 
neath the epithelium. The result of the operation upon the sight 
was excellent. Sometimes earthy or metallic incrustations are 
formed upon the cornea, and give rise to peculiar opaque or chalky- 
looking specks. This occasionally occurs from the contact of quick- 
lime or the deposits formed from lead lotion in cases of ulcers or 
abrasions of the cornea. Here I must again warn the reader against 
the use of collyria containing lead in cases of ulcer of _ the cornea 
or even abrasion of the corneal epithelium, for the precipitation of 
the lead gives rise to a very marked white stain, which produces 
great impairment of sight if it be situated in the centre of the 
cornea. 

The prognosis in cases of opacity of the cornea will depend very 
much upon the age and constitution of the patient, and upon the 
duration, extent, situation, and nature of the opacity. Thus, in 
children and young persons in good health, opacities, the result 
even of extensive corneitis or deep ulcers, may in time disappear 
almost completely, without leaving, perhaps, any trace behind. I 
have already stated that this may even occur in small perforating 
ulcers, which have given rise to central capsular cataract. With 
regard to the opacities due to inflammatory changes in the corneal 
tissue, it may be laid down as a general rule that the more recent, 
superficial, and limited such opacities are, the more rapidly and 
completely do they disappear. By the application of irritants to 
the eye, we may greatly assist in removing the cloudiness due to 
inflammatory changes in the corneal and epithelial cells. We thus 
excite hyperemia of the parts, increase the interchange of material, 
and accelerate and stimulate the process of absorption. When the 
opacities are due to permanent cicatricial changes, these applica- 
tions are of no avail, and we must then have recourse to other 
remedies if the opacity causes any impairment of vision. If the 
opacity is dense and situated in or very near the centre of the 
cornea, the sight may be very considerably affected, as it will 
more or less cover the pupil. But even slighter opacities may 
somewhat impair and confuse the vision, by the diffusion arid 
irregular refraction of the rays of light which they produce. But, 
apart from this effect upon the sight, these opacities may give rise 
to other complications. Thus, on account of the indistinctness of 
the retinal region produced by the cloudy state of the cornea, the 
patient will bring small objects (as in reading, sewing, etc.) very 
close to the eye, in order to gain a larger and more distinct image. 
But this constant accommodation for a very near point, after a 
time causes the lens to forfeit some of its elasticity, so that it can- 
not resume its original form, and the accommodation cannot relax 
itself completely when the eye is looking at distant objects. The 

1 "Diseases of the Eye," 3d edition, p. 114. 

2 " Lectures on parts concerned in the Operations on the Eye," pp. 38 and 117. 



OPACITIES OP THE CORNEA. 145 

lens remains too convex, and the eye has become myopic. The 
myopia may be also in part due to a change in the shape of the 
eyeball, produced by constant and long-continued accommodation 
for near objects (vide article " Myopia"). Opacities of the cornea 
may also give rise to oscillation of the eyeballs, and to strabismus. 
Innumerable local remedies have been recommended for the dis- 
persion of opacities of the cornea. From amongst these we may 
select the following as the most trustworthy and efficacious : The 
insufflation of calomel, the red or yellow oxide of mercury oint- 
ment, collyria of iodide of potassium, vinum opii, nitrate of silver, 
sulphate of copper, and the sulphate of soda. A small quantity of 
the latter may be dusted into the eye, or it may be used as a colly- 
rium, about 1 — 2 grains to gj of water. Together with the use of 
any of these agents, atropine should be applied, as it diminishes 
the intra-ocular pressure, and thus facilitates the interchange of 
material and the process of absorption. I have generally found it 
best, first to dust in calomel for a few days, in order to see how 
the eye bears this, and then, if it does not excite too much irrita- 
tion, to employ a stronger irritant, especially the red or yellow 
oxide of mercury ointment. At first its strength should not, I 
think, exceed one or two grains to the drachm of lard. A little 
portion, about the size of a couple of pins' heads, should be placed 
on the inside of the lower eyelid, by means of a probe, and the lids 
should then be rubbed over the cornea, so that the ointment may 
come well in contact with it. If the yellow precipitate ointment 
be used of greater strength than that mentioned above, it should 
be removed after a few minutes, otherwise it will produce too much 
irritation. If it is found that the ointment excites a great deal of 
irritation, redness, and pain, a smaller quantit}', or a weaker prepar 
ration should be used, or the calomel should be again substituted 
for a few days. Generally, it is better if the surgeon can himself 
apply these remedies, as he is then able to watch their action upon 
the eye ; but if the proper mode of using the calomel or the oint- 
ment be explained and shown to the patient, I have found no 
difficulty in getting these remedies applied by the patient himself, 
or his frieuds. But if I do not apply the ointment myself, I never 
prescribe it stronger than gr. i — ii ad 3j ; as the stronger prepara- 
tion requires to be removed from the conjunctiva after 2—3 minutes. 
I have also found advantage from the application of iodide of potas- 
sium, either in a collyrium or mixed with the yellow precipitate, 
in the following proportion: Iodide of potassium gr. j, Yellow 
oxide of mercury gr. ij, Adipis 3j — 3ij- The instillation of a little 
vinum opii also proves very useful. Nitrate of silver or sulphate 
of copper are only indicated when there is any inflammatory 
swelling of the conjunctiva, accompanied by some muco-purulent 
discharge. After any of these remedies have been used for some 
length of time, they should be exchanged for some other agent, as 
the eye gets accustomed to them, and they appear temporarily to 
lose their effect. 
10 



146 DISEASES OF THE CORNEA. 

Eleetrictity was formerly in vogue for the cure of ojiacities of 
the cornea. It has now, however, fallen into disuse. 

Dr. Rothmund, 1 of Munich, has lately strongly recommended the 
subconjunctival injection of tepid salt and water in cases of dense 
non-vascular opacities, such as often remain after diffuse corneitis. 
The strength of his solution varies from 9j — 3j of Salt to 3j of 
Water. 

[M. Wecker' has recently advocated the method of tattooing for 
the removal of the cosmetic defect produced by dense leucomata. 
The operation, which, as a rule, causes very little pain or irritation, 
is best performed with a number of the finest needles firmly bound, 
with the point on a level, around a handle, such as a penholder. 
The substance which M. Wecker recommends for tinting is India 
ink; Mr. Taylor has also employed, 3 with advantage, sepia, ultra- 
marine, and other colors, and, when an immediate and deeply col- 
ored effect has been desired, a combination of lamp-black with India 
ink, and a solution of nitrate of silver. The needles are dipped 
into the pigment solution, which should be made as thick as pos- 
sible, and, the eye being steadied, the superficial layers of the cica- 
trix are rapidly punctured in an oblique direction, and layers of 
the solution applied just as.in ordinary tattooing.] 

The chalky incrustations, or deposits of lead upon the cornea, 
should be carefully scraped off with a cataract or sickle-shaped 
knife [Fig. 41]. If they are extensive, the whole need not be 
removed, but only a portion sufficiently large to un- 
[Fig. 41.] cover the pupil. As this operation is sometimes very 
painful, it had better be done under chloroform, espe- 
cially in children. Afterwards, a little olive oil or 
atropine should be applied to the eye. 

But if the opacity resists all these remedies, and 
materially impairs the sight, we must endeavor to im- 
prove vision, either perhaps by some optical arrange- 
ment, or by the formation of an artificial pupil oppo- 
site a clear portion of the cornea. For the purpose of 
diminishing the effect of the diffusion and irregular 
refraction of the rays produced by the cloudiness, the 
stenopaic spectacles will often be found of great use 
(Donders). 4 They consist of an oval metal plate, having 
a small central aperture. The effect of this is to per- 
mit only the central rays, which fall in the optic axis, 
to pass, whereas all the peripheral, diffused light is excluded. If 
necessary, convex or concave lenses may be applied behind the ap- 
paratus. Although these stenopaic spectacles often answer ad- 
mirably for any employment at near objects, e. g., reading, sewing, 

1 " Klinische Monatsbliitter f. Augenheilkunde," 1866, p. 161. 
[ 2 Archives of Ophthalmology and Otology, vol. ii., No. 2. p. 224. 
» American Journal of the Medical Sciences, October, 1872, p. 561.] 
* "A. f. O." i. 1, 251 ; vide also Donders' "Anomalies of Accommodation and 
Kefraction of the Eye." New Syden. Society, p. 128. 



OPACITIES OF THE CORNEA. 147 

engraving, etc., they cannot be used for walking about, as they 
produce too great a contraction of the field of vision. 

An artificial pupil may be made either by means of an iridectomy, 
an iridodesis, or iridoenkleisis. If the opacity is confined to the 
centre of the cornea, it will be best to perform iridodesis or irido- 
enkleisis, for, by so doing, we can draw the iris somewhat forward 
opposite the opacity, and thus diminish the diffusion of light pro- 
duced by the latter; moreover, the apex of the artificial pupil will 
be opposite the edge of the lens, and will thus prevent the irregular 
refraction which would be caused if the periphery of the lens were 
widely exposed by an iridectomy. But if the opacity is more con- 
siderable, and does not leave a wide margin of clear cornea, the 
artificial pupil thus made will be insufficient, more especially with 
regard to the amount of light admitted into the eye, and in such 
cases it is better to make an iridectomy, which should, however, 
be but small. If the margin of transparent cornea is very narrow, 
there is always the danger that the wound made in the perform- 
ance of iridectomy may produce a certain degree of fresh opacity 
of the small portion of clear cornea near it, and thus militate against 
the benefit derived from the operation. In order to obviate this 
danger, we may make the artificial pupil by corydialysis, which 
would, of course, produce no cloudiness of the cornea opposite to the 
new pupil, the incision being made at another portion of the cornea. 
An artificial pupibshould always be made opposite that portion of 
the cornea which is the most clear, and has the truest curvature. 
The direction inwards, or slightly downwards and inwards, is by 
far the best for optical purposes, for not only does the artificial 
pupil then correspond to the visual line, but it also assists better 
in the binocular vision (Gemeinschaftlicher Sehact) with the other 
eye. If any anterior synechia exists, and its extent is but small, it 
may be divided with the point of the broad needle or iridectomy 
knife, in the performance of iridodesis or iridectomy. If it is of 
recent formation (as after an incised or punctured wound of the 
cornea), the adhesion is often so slight that it may easily be de- 
tached with a blunt hook or a small spud. 

[A mode of treatment of dense leucomata has recently been 
devised by Mr. Henry Power, 1 of London, and practised on the 
human subject with " promising results." It consists in removing 
a portion of' the opaque cornea of the patient with a sharp punch, 
specially devised for the purpose, and obtaining, by the same means, 
an exactly corresponding portion of a healthy rabbit's cornea and 
transferring it to the space in the human eye. The lids are then 
to be fixed together, and in a week, Mr. Power has found union to 
be complete. "Whether the portion transplanted will become per- 
fectly clear he cannot yet, from want of experience, say.] 

I need hardly say that the experiments made by Nussbaum and 
others to cut a hole in the opaque cornea and insert a piece of glass, 
have completely failed. 

[' Med. Times and Gaz., Aug. 10, 1872.] 



148 DISEASES OF THE CORSEA, 



$.— ARCrS SENILIS. 



This peculiar marginal opacity of the cornea is due to fatty de- 
generation of the corneal tissue, which generally commences first 
in the upper portion of the cornea. It then shows itself in the 
lower, and the extremities of the two arcs increase more and more, 
until at last they meet and encircle the whole cornea. TTe are 
chiefly indebted to Mr. Canton 1 for an exact and extensive knowl- 
edge of this condition : he has fouud that it generally occurs about 
the age of 50, but that it may appear at a much earlier age, espe- 
cially in families in which it appears to be hereditary. He also 
considers that the areus senilis affords us the best indication of 
the proneness of other tissues to fatty degeneration. 

The opacity is at first of a light gray color, appearing like a 
narrow, silvery rim near the edge of the cornea, but not reaching 
quite up to the latter, being always divided from it by a trans- 
parent portion of cornea. At a later period, the opacity assumes 
a denser and more creamy-tint, and increases iu depth and width, 
being generally broader above and below than at the sides. It 
might be supposed that the fatty degeneration of the corneal tissue 
would impede or prevent the union of an incision lying in this 
part of the cornea. This is, however, not the case, for we find that 
a section carried through the areas senilis heals perfectly, as may 
be often observed in cases of extraction of cataract. 



9— CONICAL CORNEA. 

"When this affection is but slight, a cursory observer may easily 
overlook it, and mistake it, perhaps, for a case of myopia, "compli- 
cated with weakness of sight (amblyopia). But a marked case 
q cannot well be overlooked. On regarding 

such an eye from the front, we notice that 
the centre of the cornea appears unusually 
glistening and bright, as if a tear-drop 
were suspended from it. If we then look 
at it in profile, the size and shape of the 
conicity will become at ouce apparent. [Fig. 
■i-]. Sometimes the conicity is not in the 
centre, but nearer the margin of the cornea. 
But by means of the ophthalmoscope, even 
the slightest cases of conical cornea may be diagnosed with cer- 
tainty, as was first pointed out by Mr. Bowman. 2 For this purpose 
the mirror alone is to be used, without the convex lens in front. 
On throwing the light upon the cornea, we receive a bright red 
reflection through the centre of the cornea, which gradually shades 
off, and becomes darker towards the base, so that the central bright 

1 Vide Mr. Edwin Canton's work, " On the Arcus Senilis." London, 1863. 
' "R. L. O. H. Rep.." ii. 154. 




CONICAL CORNEA. 149 

red spot is surrounded by a dark zone, which in its turn is again 
encircled by a red ring. If we throw the light upon the centre of 
the cornea at different angles, the side of the cone opposite to the 
light is darkened. The central red zone (in which we obtain a 
reverse image of the disk, etc.) is due to the reflection of the fundus 
through the central conical portion of the cornea, and the outer 
red ring to the reflection through the normal peripheral portion of 
the cornea. The dark zone between the two is, according to 
Knapp,' due to the diffusion and complete reflection of the rays of 
light at the base of the cone, where it passes over into the normal 
curvature of the cornea. 

On the ophthalmoscopic examination of the fundus of an eye 
affected with conical cornea, we notice a considerable parallax on 
moving the convex lens in front of the patient's eye. 2 In this way 
we can produce a distortion and displacement of a certain portion 
of the disk and retinal vessels, whilst the other part of the disk 
remains immoveable, just as occurs in glaucomatous excavation of 
the optic nerve. 

Even in slight cases of conical cornea, the patients always com- 
plain of considerable, and often great impairment of sight. On 
account of the conicity of the central portion of the cornea, the 
antero-posterior axis is increased in length, and hence the eye has 
become more or less myopic, and the patient consequently holds 
small objects (as in reading, etc.) very close to the eye. But the 
impairment of sight is chiefly due to the astigmatism caused by 
the irregular curvature of the cornea, which gives rise to great 
distortion and confusion of the retinal images. Concave spherical 
lenses, therefore, generally produce but slight improvement, but 
some benefit is occasionally derived from cylindrical glasses, al- 
though the astigmatism is as a rule too irregular to admit of 
much correction. More improvement is found from the use of a 
circular or slit-shaped stenopaic apparatus, fitted, perhaps, with a 
suitable concave lens, as this diminishes the circles of diffusion 
upon the retina by cutting off the peripheral rays of light. We 
often notice that the patients endeavor to accomplish this for 
themselves by nipping their eyelids together, so as to change the 
palpebral aperture into a narrow slit. After the disease has ex- 
isted a certain time, and reached a high degree of development, 
the apex of the cone often becomes opaque, and thus the sight is 
still more deteriorated. 

The bulging forward of the cornea is not due to an increase in 
the intra-ocular tension (which is indeed rather slackened), but to 
a diminution in the power of resistance of the cornea, and as this 
bulging increases, the portion of cornea embraced in it becomes 
thinner and thinner. It is an interesting fact, that however at- 
tenuated the apex may become, it never gives way, except through 
an accidental injury. Mr. Bowman thinks that the reason of this 

1 "Kl. Monatsbl.," 18G4, 313. 

2 Donders, "A. f. O.," 7, 199 ; also Donders, op. clt. , 551. 



150 DISEASES OF THE COE.VEA, 

is, that " as the cornea becomes thinner, the escape of the aqueous 
humor by exosmose is facilitated, and thus the internal pressure is 
reduced, so as to be no longer in excess of the diminished resisting 
power of the cornea. A balance is established like that of health, 
only that there is a more than ordinary outflow of the aqueous 
humor by transudation through the cornea. This accords with my 
previous observation, as to such eyes being rather unduly soft." 

The progress of the disease is generally very slow. It may be- 
come stationary at any point, stopping short when the conicity is 
still but slight, or going on until it is very considerable and the 
apex has become clouded. It generally sooner or later attacks 
both eyes. It occurs frequently, but not always, in persons of a 
delicate constitution, and commences chiefly between the ages of 
15 and 30. Mr. Bowman has observed a very few cases in which 
it occurred in more than one member of the same family. Any 
considerable and protracted use or straining of the eye in reading, 
sewing, etc., will tend to increase its development and produce local 
irritation and congestion. 

Innumerable remedies have been suggested and tried for the 
relief and cure of conical cornea, but almost all of them without 
success. If the patient is in delicate health, tonics and a nutritious 
diet with plenty of fresh air and exercise should be prescribed, and 
the use of the eyes for reading, etc., should be forbidden if both are 
affected. In order to neutralize the myopia produced by the coni- 
city of the cornea, Sir ~W. Adams removed the lens. Mr. "Wardrop 
recommended frequent tapping of the anterior chamber. Mr. 
Tyrrell was the first to make an artificial pupil in this disease, and 
this is the treatment which has hitherto proved most successful. 
The purpose we have in view in making an artificial pupil is two- 
fold : 1st. To improve vision by making a pupil opposite a portion 
of the cornea which has retained its normal curvature; 2d. To 
arrest the progress of the disease, and, if possible, to cause it to 
retrograde somewhat by diminishing the intra-ocular pressure. 

The artificial pupil may be made either by an iridectomy or an 
iridodesis. By the former operation, we certainly bring the pupil 
opposite a marginal portion of the cornea, but there is this disad- 
vantage, that the original pupil remains opposite the conicity, and 
therefore the rays which pass through it are diffused and irregu- 
larly refracted, and thus confuse the retinal image and diminish its 
distinctness ; whereas, by means of an iridodesis we can draw the 
iris well forward towards the incision, and thus displace the pupil 
towards a portion of the cornea which is less irregularly curved, 
and bring the iris opposite the cone. The incision should be made 
slightly in the sclerotic, so that the plane of the iris may not be moved 
away from. the lens. The best direction for the iridodesis is 
slightly downwards and inwards. In order to obtain the advan- 
tages which are derived from a slit-shaped stenopaic apparatus, 
Mr. Bowman has made a double iridodesis, so that an oblong slit- 
shaped pupil is obtained. This may be made either vertical or 
horizontal. In the former case we have the advantage that a con- 



CONICAL CORNEA. 151 

siderable portion of the angles of the slit is covered by the lids, 
which renders it much less unsightly, more especially if the irides 
are light in color, than the horizontal slit, which gives the appear- 
ance of a cat's eye. The operation should not be performed in 
opposite directions at the same sitting, as the point first tied is 
apt to yield and be drawn into the anterior chamber again, when 
the iris is drawn towards the opposite incision. It is best to make 
the second iridodesis about eight or ten days after the first. The 
incision should be made in the sclerotic, so as to retain the normal 
plane of the iris. 

Not only does this operation produce a beneficial effect in an 
optical point of view, but it also sometimes causes a considerable 
diminution in the bulge of the cornea and the progress of the 
disease. At present it is very difficult to decide upon the point as 
to which operation is really the best, as the results have varied con- 
siderably. For instance, in some cases benefit has been produced 
in the sight by the second iridodesis, whereas in others again this 
has not been the case. The improvement is, however, never so 
conspicuous as after the first operation. My own experience 
rather tends to the opinion that on the whole the progress of the 
disease is most arrested and the bulging of the cornea most dimin- 
ished by an iridectomy. Care must, however, be taken to make it 
only moderate in size, and perhaps slightly upwards and inwards, 
so that a part of the base of the artificial pupil may be covered by 
the upper lid. In slight cases, in which the conicity is either 
almost stationary or but very slowly progressive, I think iridodesis 
is indicated, whereas if it is considerably and markedly progressive, 
an iridectomy is to be preferred. 

Von G-raefe has lately published a very interesting case of coni- 
-cal cornea, in which he produces ulceration of the apex of the cone, 
and subsequent contraction and flattening of the cicatrix. 1 The 
fact that the cicatricial contraction which follows extensive ulcers 
or infiltrations of the cornea always produces a certain degree of 
diminution or flattening of the curvature of the cornea, led Von 
Graefe to the idea that a similar effect might be brought about in 
severe cases of conical cornea, by the artificial production of a little 
ulcer. The operation is to be performed in the following manner : 
— The point of a very small knife, made of the shape of Von 
G-raefe's narrow cataract knife, but smaller in size, is to be passed 
into the middle layers of the cornea, just at the apex of the cone, 
to the extent of about a line, and then brought out again ; so that 
a very small superficial flap may be formed, which is then to be 
seized with a very fine pair of forceps and snipped off at its base 
with a pair of curved scissors, thus leaving a superficial gap at this 
point. Great care must be taken that the knife does not penetrate 
the cornea, of which there is the greatest risk on account of the 

1 " A. f. O.," 12, 2, 215. More recently Von Graefe has published an elaborate 
and interesting paper upon this subject in the " Berlin Klinische Wochensohrift, " 
1868, No. 23. 



152 DISEASES OF THE CORNEA. 

extreme tenuity of the cornea at the apex of the cone. Should, 
however, perforation occur, the operation should be postponed for 
a few days, until the aperture is closed. The day after the opera- 
tion, the floor of the gap is to he lightly touched, at two or three 
points, with a finely pointed crayon of mitigated nitrate of silver 
(nitrate of silver 1 part, nitrate of potash 2 parts), the effect of the 
cauterization being at once neutralized by the application of salt 
and water. The application of the caustic is to be repeated at 
intervals of from three to six days, until a slight, faintly-yellowish 
infiltration is formed, with but a moderate degree of pericorneal in- 
jection, when w r e may consider the effect as sufficient, and simply 
apply atropine to the eye and guard it against exposure. The 
cauterization generally produces but very little irritation. Should 
the infiltration show a tendency to assume the character of a per- 
forating ulcer, the compress bandage must be employed alternately 
with warm aromatic fomentations, and it may even be necessary to 
perform paracentesis. The improvement of the sight will not be at 
once apparent, indeed at first it may even be deteriorated, but at 
the end of five or six weeks, when the infiltration begins to con- 
tract, it rapidly increases, the little cicatricial opacity gradually 
diminishes in size and density, and leaves the sight greatly im- 
proved. Von GTraefe has performed this operation with great suc- 
cess in several case3 of severe conical cornea, and has gained much 
better results than from the formation of an artificial pupil. Mr. 
Critchett has lately likewise obtained a most successful result by 
this proceeding in a case of double conical cornea. 

[In cases of extreme conical cornea, Mr. Bader contends that a 
greater improvement of sight is obtained by removal of the top of 
the cone than by any of the other modes of treatment. He passes 
a delicate curved needle, armed with fine silk or silver wire, through 
the cornea, in its horizontal diameter, close to the point of the 
cornea to be removed. The point of the needle is then carried 
horizontally across the aqueous chamber, and is thrust through a 
point of the cornea opposite to the point of entrance, and close to 
the portion of cornea intended to be removed. The needle is left 
in the cornea until the top of the cone has been removed, as it 
helps to protect and keep back the lens. The head of the needle 
is held in one hand, and the lower half of the cone is divided with 
a Beer's knife, the needle is then let go, the small flap seized with 
an iris-forceps, and the rest of the cone removed with scissors. The 
needle is now to be drawn wholly through the cornea, and the 
wound united by tying the thread. Mr. Bader reports 1 nine cases 
thus treated, and in all, the conical cornea completely disappeared, 
and gave way to an abnormally flat cornea.] 

1 Lancet, Jan. 20, 1872. 




KERATO-GLOBUS. 153 



10.— KERATO-GLOBUS (HYDROPHTHALMIA ANTERIOR 
HYDROPS OF THE ANTERIOR CHAMBER). 

This disease is characterized by a uniform spherical bulging of 
the whole cornea, so that it is increased in size in all its diameters. 
[Fig. 43.] Generally, however, this increase 
in size is not confined to the cornea, but ex- 
tends to the neighboring portion of the scle- 
rotic. The augmentation in the size of the 
anterior half of the eyeball is often so consider- 
able, that the eye protrudes between the pal- 
pebral aperture, and. prevents the easy closure 
of the eyelids. On account of the peculiar 
staring appearance which this gives to the eye, 
the disease has also been termed " buphthalmos.'[ 
True hydrophthalmosorbuphthalmos is always 
congenital. For an important and very interesting account of this 
disease, I would refer the reader to a dissertation on Hydroph- 
thalmos congenitus, by Dr. Wilhelm v. Muralt, of Zurich, 1 based 
on cases which occurred in Professor Horner's Clinique. 

The cornea may either remain transparent or become slightly 
opaque near the periphery ; in other cases the cloudiness may be 
more considerable, and extend over the greater portion of the sur- 
face of the cornea. The anterior portion of the sclerotic is much 
thinned and of a blue tint, which is due to a shining through of 
the choroid. The size of the anterior chamber is much increased, 
both in depth and circumference. The aqueous humor is generally 
clear. The iris is also enlarged, and the fibres near its ciliary 
margin are stretched and opened up ; the pupil is generally some- 
what dilated and sluggish, and perhaps here and there adherent to 
the capsule. The iris is often somewhat cupped back, which in- 
creases still more the depth of the anterior chamber, and it may 
also be tremulous, which may be either due to dislocation of the 
lens, caused by a stretching and giving way of its suspensory liga- 
ment, or to the iris being no longer in contact with the anterior 
surface of the lens, but divided from it by a collection of fluid in 
the posterior chamber. Sometimes, however, the iris is bulged 
forwards. But as the disease advances, the optic disk becomes 
excavated from the permanent increase in the intra-ocular tension, 
the lens becomes opaque, the vitreous humor fluid, the retina per- 
haps detached, and atrophy of the eyeball may close the scene. On 
account of the great attenuation of the anterior portion of the 
coats of the eye, even a slight blow may suffice to rupture the 
globe. But whether this may occur spontaneously is doubtful. 
The state of the sight varies very considerably. In some cases, 
the patient can still decipher moderate sized print ; in others it is 
greatly impaired, which may be due to the opacity of the cornea, 

1 Zurich, published by Ziircher and Furrer, 1869. 



154 



DISEASES OF THE CORNEA. 



or to inflammation of the deeper tunics of the eye. As a rule the 
disease terminates sooner or later in blindness. 

The affection does not appear to be due to an increased secretion 
of the aqueous humor, but to a thinning and diminution in the 
power of resistance of the cornea, following generally upon severe 
and extensive inflammations of the cornea, as, for instance, vascular 
corneitis or pannus. The opacity may afterwards disappear, but 
the bulging remains, and even gradually augments. Treatment, 
unfortunately, is but too often of little avail. The most is to be 
expected from a large iridectomy. The patient's general health 
should be strengthened, and the eyes be but moderately employed. 
If the protrusion is very considerable, the cornea opaque, and the 
sight almost entirely gone, an operation for staphyloma may be 
indicated, not only for the sake of appearance of the eye but also 
to alleviate the inconvenience and constant irritation kept up by 
the incomplete closure of the eyelids. 



11— STAPHYLOMA OF THE CORNEA AND IRIS. 

We have already seen that when an ulcer of the cornea causes 
perforation of the latter, the aqueous humor flows off', the iris falls 
forward, and, may become adherent to the cornea. If the perfora- 
tion is but of slight extent, an anterior synechia will be produced, 
without perhaps any bulging of the cornea at this point. But if 
the opening is large, a considerable portion of iris- will fall against 
or into the gap, and perhaps protrude through it, giving rise to a 



[Fig. 44. 



Fig. 45. 





Side view. After Mackenzie. 



Front view. After Dalrjmple.] 



more or less extensive prolapse. This is soon covered with a layer 
of lymph, which becomes organized, gradually assumes a cicatricial 
character, and replaces the cornea at this point, to which it may 
indeed bear a certain outward resemblance. It is, however, much 



STAPHYLOMA OF THE CORNEA AND IRIS. 155 

weaker and less elastic, so that it readily yields to the intra-ocular 
pressure, gradually bulges forward, and gives rise to a partial sta- 
phyloma. [Figs. 44, 45.] If the latter is situated at the margin 
of the cornea, the pupil may remain partially or entirely free, and 
a certain amount of sight be preserved. But if the prolapse occurs 
in the centre, the whole pupil will be involved. A partial staphy- 
loma may gradually increase, until it implicates the surrounding 
cornea to a considerable extent, and if the perforation was origin- 
ally of large size, it may, finally, even involve the whole cornea, 
and become changed into a total staphyloma. When the projection 
has become at all considerable, so as to protrude somewhat between 
the lids, its exposure to the action of external irritants is apt to 
produce occasional inflammatory exacerbations, which tend to cause 
a still greater increase in the size of the staphyloma. 

The most frequent causes of partial staphyloma are sloughs and 
ulcers of the cornea, wounds and injuries, and also certain opera- 
tions upon the eye, as for instance, flap extraction, which may be 
followed by a considerable prolapse of the iris and the formation of 
a partial staphyloma. 

N"o time should be allowed to elapse before the tendency to sta- 
phyloma is checked. Thus if a prolapse of the iris has occurred, it 
should be treated at once by the proper remedies. The best treat- 
ment for partial staphyloma is undoubtedly by iridectomy, as this, 
by diminishing the intra-ocular pressure, not only prevents the in- 
crease of the bulging, but generally also causes it to decrease in 
size. The artificial pupil should be made opposite to the most 
transparent portion of the cornea. I must here again mention the 
very important fact that cases of partial or complete staphyloma are 
sometimes accompanied by marked increase of tension, so that the 
eye is in a glaucomatous condition, and the degree of impairment 
of vision quite disproportionate to the amount of staphyloma and 
opacity of the cornea. In such cases there will be increase of ten- 
sion, accompanied perhaps by contraction of the field, eccentric fixa- 
tion, and excavation of the optic nerve. In all cases of staphyloma 
the degree of tension, the state of the sight and of the field of vision 
must therefore be carefully watched, and an iridectomy must be on 
no account delayed if symptoms of glaucoma supervene. I think 
this treatment of partial staphyloma by iridectomy greatly prefera- 
ble to that which was formerly much in vogue, viz., the touching 
the protrusion with nitrate of silver, and thus changing it into an 
ulcer which, on cicatrizing, would produce a flattening and shrink- 
ing of the staphylomatous tissue. This is apt to set up considerable 
irritation, and proves far less efficacious than an iridectomy. Par- 
tial abscission may also be performed by a modification of Critchett's 
operation. 




156 DISEASES OF THE CORNEA. 

12— TOTAL STAPHYLOMA OF THE CORNEA AND IRIS. 

This only occurs in cases in which there has been an almost total 
destruction of the cornea by sloughing or ulceration. Its shape is 

r generally spherical [Fig. 46], although 

[Fig. 40.] occasionally it may be conical. The 

neighboring portion of the sclerotic 
mostly becomes implicated in the pro- 
cess, and the staphyloma may, in time, 
involve the anterior half of the eyeball. 
The lens may either have escaped at the 
time of the perforation, or have remained 
behind, in which case it often becomes 
opaque. Its position within the eye 
varies; it generally lies in close contact 
with the iris and the cicatricial tissue, 
to which it becomes adherent; it may, however, be separated from 
the iris by a considerable amount of aqueous humor, which forms 
a large posterior chamber; or, again, it may have become detached 
from the suspensory ligament and have sunk down into the vitreous 
humor. 

The presence or absence of the lens after an extensive perforation 
of the cornea exerts great influence upon the formation of a sta- 
phyloma. If the lens escaped, at the giving way of the cornea, a 
firm cicatrix is fanned, which will generally resist the intra-ocular 
pressure, and not bulge forward, but will often become consolidated, 
contract, and lead, perhaps, to a certain degree of shrinking of the 
globe. It is different, however, if the lens has remained within the 
eye, for it then bulges forward, and presses upon the newly formed 
cicatricial tissue, which gradually yields and becomes staphyloma- 
tous. If, therefore,, a case of extensive perforation of the cornea, 
with a tendency to staphyloma, is seen at an early stage, and the 
lens is found pressing against the cicatrix, it is best to remove it 
at once, so as to allow the cicatrix to become firm and consolidated. 
The lens may be removed by making an incision into the staphy- 
loma with Graefe's cataract knife, dividing the capsule, and allow- 
ing the lens to escape. Or, it may be done according to the follow- 
ing proceeding of Mr. Bowman, which I have seen answer remark- 
ably well in several cases. He passes a broad needle through the 
staphyloma into the lens, and breaks this freely up. The needle 
having been withdrawn, a curette is passed through the same open- 
ing, and the soft lens matter allowed to escape. The breaking up 
of the lens may be repeated at intervals of a few days. The sta- 
phylomatous protrusion will gradually subside, the cicatrix will 
become firm and consolidated, and the eye perhaps shrink some- 
what. When all symptoms of irritation have subsided, an arti- 
ficial eye may often be worn without the necessity of any further 
operation. 

As we cannot restore any sight in cases of total staphyloma, the 



TOTAL STAPHYLOMA OF THE CORNEA AND IRIS. 



object of our treatment must be to remove the protrusion, so as to 
free the patient from the pain and inconvenience which generally 
attend this disease, and also to improve the personal appearance 
and permit of the adaptation of an artificial eye. There are nu- 
merous modes of operating for staphyloma, of which the following 
only require mention : 1, Excision. 2, Mr. Critchett's operation 
of abscission. 3, Graefe's seton operation. 4, Borelli's operation. 
1. Excision. — This is best performed in the following manner. 
The point of a cataract knife (the edge of which is turned down- 
wards, as in Fig. 47), is to 



\ 




After Stellwag. 



be passed into the sclerotic, Flg ' ^ 7- 

near the edge of the staphy- 4 

loma, and somewhat above jj| 

its horizontal diameter, so 
that about § of the staphy- 
loma may be included in the 
incision. The blade of the 
knife is to be carried on 
parallel to the base of the 
tumor, until its point makes 
its exit at the opposite side, 
at a spot corresponding to 
the puncture. The knife 
should then be pushed slowly 
on, until it has cut its way 
out and divided the lower § 
of the staphyloma, by a large 
flap-shaped incision. The remaining portion is next to be divided 
by the aid of a pair of scissors. A bandage is then to be applied, 
either together with water dressing or a simple pledget of lint. 
Lymph will be effused from the edges of the incision, and a more 
or less firm cicatrix result ; the eyeball will shrink somewhat, but 
leave perhaps a tolerably good stump for the application of an arti- 
ficial eye. The result of the operation is not, however, always so 
favorable. A considerable gush of vitreous humor may follow 
upon the excision of the anterior portion of the eye, and intra- 
ocular hemorrhage ensue. Or, again, suppuration of the eye may 
take place, accompanied, perhaps, by very violent pain and inflam- 
mation. The eyeball then shrinks and dwindles down, leaving 
but a very small and inefficient stump, with a slight degree of 
movement, for the application of an artificial eye. To obviate 
these disadvantages, Mr. Critchett has employed the following in- 
genious and valuable operation of abscission, which leaves an ex- 
cellent, large, moveable stump. 

2. Mr. Crittchett's 1 operation of abscision is to be performed 
thus : " The patient being placed under the influence of chloroform, 
the staphyloma is freely exposed by means of a wire speculum ; a 
series of four or five rather small needles, with a semicircular curve, 



1 "Roy. Lond. Oplith. Hosp. Reports." iv. 1. 



158 DISEASES OF THE CORNEA. 

are passed through the mass, about equi-distant from each other, 
and at such points as the lines of incision are intended to traverse 
(Fig. 48). These needles are left in this position, with both 
extremities protruding to an equal extent from the staphyloma. 




The advantages gained by this part of the proceeding are : 1. That 
a small quantity of the fluid parts of the distended globe escapes, 
thus diminishing pressure, and preventing a sudden gush of the 
contents, when the anterior part is removed. 2. That the points 
of emergence indicate the lines of incision. 3. That the presence 
of the needles prevents, or rather restrains, to some extent, the 
escape of the lens and vitreous humor, after the anterior part of 
the staphyloma has been removed. The next stage of the pro- 
ceeding is to remove the anterior part of the staphyloma. This 
requires some judgment and modification in size and form, in ac- 
cordance with the extent of the enlargement, so as to leave a con- 
venient bulb. My usual plan is to make an opening in the sclerotic, 
about two lines in extent, just anterior to the tendinous insertion 
of the external rectus, made with a Beer's knife [Fig. 49]. Into 
this opening I insert a pair of small probe-pointed scissors, and cut 
out an elliptical piece, just within the points where the needles 
have entered and emerged. The needles, armed with tine black 
silk, are then drawn through each in its turn, and the sutures are 
carefully tied, so as to approximate as closely as possible the divided 
edges of the sclerotic and conjunctiva (Fig. 50). The operation is 
now finished ; the speculum may be removed so as to allow the lids 
to close, and wet lint may be applied to keep the parts cool. In a 
large majority of cases, union of the divided edges takes place by 
the first intention." . ..." I generally leave the sutures in 
for some weeks. Sometimes they come away spontaneously, and 
when this is not the case, they may readily be removed after all 
irritation has passed away, and after firm union has taken place. 
If the case be examined three or four months after the operation, 
a moveable bulb is seen with a flattened anterior surface, traversed 



TOTAL STAPHYLOMA OF THE.COENEA AND IRIS. 159 
[Fig. 49.] Fig. 50- 




After Lawson. 



by a white line of cicatrix, and having rather a promi- 
nent external angle. Upon this an artificial eye can be 
readily adapted, which moves to a greater extent than I 
have observed previous to adoption of my present 
method." 

Care must be taken in making the incision, so to 
slope and bevel off the angles, that the lips of the wound 
here fit very accurately and neatly, otherwise an awk- 
ward pucker may be left at these points, which will 
interfere materially with the comfort of wearing an 
artificial eye. It is always best, except perhaps in young 
children, or where the staphyloma is small, to employ 
five sutures, in order that too great an interval may not 
be left between them, for if this be the case, beads of 
vitreous will protrude, become covered with granula- 
tions, and suppurate somewhat. My experience of Mr. 
Critchett's operation has certainly been most favorable, 
and I can entirely endorse his statement, that we gain by 
it a better and more perfectly moveable stump for an 
artificial eye, than by any other operation. I do not, how- 
ever, think it indicated in those cases in which the disease 
is not confined to the anterior portion of the eyeball, 
but the inflammation has extended to the retina and cho- 
roid. For in such cases, the operation is not only often 
followed by perhaps immediate and severe intra-ocular hemorrhage 
leading to suppuration of the globe, but we leave behind a part of 
the diseased structure, which may not only become again inflamed, 
but, what is still more to be dreaded, be the cause of sympathetic 
inflammation in the other eye. In all such cases, it is therefore 
undoubtedly by far the safest plan to remove the whole eyeball, as 
this frees us from all fear of sympathetic ophthalmia. If the pa- 
tient is in good circumstances, and is so situated that he can at 
once apply to a surgeon, if the stump becomes inflamed, or symp- 
toms of sympathetic irritation show themselves, and if he is ex- 



160 



DISEASES OF THE CORNEA. 



tremely anxious about his personal appearance, abscission may be 
performed, otherwise it is safest to remove the staphylomatous eye 
altogether. I must here state, that in the " Dublin Quarterly Jour- 
nal of Medical Science" for 1847, Vol. iii., p. 242, Mr. (now Sir 
William) Wilde, drew attention to a new operation which he had 
devised for the removal of staphyloma. " This consisted in the in- 
troduction of a curved needle through the base of the staphjdoma, 
then removing the conical projection with a cataract knife and 
scissors, drawing the needle through, and tying the ligature. Sir 
William Wilde subsequently sometimes employed several ligatures. 
In order to avoid, if possible, any risk of sympathetic irritation 
of the other eye, which might be awakened by the passage of the 
needles through the ciliary region, or the presence of the threads 
at this point for 8-14 days, Knapp 1 has devised the following mod- 
ification of Critchett's operation. Instead of passing the neeedles 
and sutures through the ciliary region or cornea, he passes them 
through the conjunctiva by means of two needles. This proceed- 
ing is illustrated in Fig. 51. A fine, threaded needle is inserted in the 

conjunctiva, about 4-5 
mm. above the base of the 
staphyloma, and some- 
what to the inner side of 
the vertical meridian (Fig. 
51, a), it is passed beneath 
the conjunctiva and sub- 
conjunctival tissue to- 
wards the nose, and 
brought out at the inner 
, . ,.-■-,-■. edge of the base of the 

yMJTifchwTiSr // -— ^) staphyloma (b). Thence 

'™fT'\v Imz^^ tne same needle and 

1 -=*"' thread are passed over 

7 \ the staphyloma to its 

171 ' lower margin c, and there 

again inserted in the con- 
junctiva and passed beneath it to d. The "same proceeding is re- 
peated on the outer portion of the staphyloma at e,f,g, h. The 
threads are then well laid back out of the way of the lines of the 
incisions, and the staphyloma excised as in Critchett's operation. 
The two ends of the thread, 1 1' and in m', are then firmly tied, so 
that the lips of the incision are brought into close contact. The 
threads are to be removed at the end of 3-4 days. 

3. Von Graefe's 2 operation by seton consists in passing a double 
thread parallel to the cornea, through the coats of the eyeball (but 
not where they are thinned) and the vitreous humor, so as to include 
them within a suture to an extent of four or five lines. The threads 
are not to be tied tightly, but left in a loose loop, and their ends 

1 "A. f. 0.,"xiv. l, 275. 

2 " Archiv. f. Ophthalmologic, ix. 2, 105. 




INJURIES AND WOUNDS OF THE CORNEA. 161 

are to be snipped oft' close to the knot. A light compress is to be 
applied to the lids. "Within from 16 to 32 hours, acute symptoms 
of suppurative choroiditis generally supervene, accompanied by sub- 
conjunctival chemosis, slight immobility of the lateral movements 
of the eye, and perhaps a certain degree of protrusion of the globe. 
The threads are then to be removed, and warm chamomile or poppy 
fomentations should be applied to alleviate the pain. The eyeball 
after a time becomes shrunk and atrophied. I have seen one case 
successfully treated by Mr. Bowman in a somewhat similar manner. 
The threads wei'e, however, left in for some time and occasionally 
moved. There were no severe symptoms of inflammation, and the 
eye gradually diminished to about half its original size, and an 
artificial eye is now worn with comfort. The great advantage of 
this proceeding is, that there is no tendency to sympathetic inflam- 
mation, which appears never to ensue upon suppurative choroiditis. 
4. Dr". Borelli transfixes the staphyloma by two needles, which 
are passed through the base of the protrusion, so as to cross each 
other at right angles. The one is entered at the temporal side, 
midway between the vertical and horizontal meridian of the cornea, 
passed beneath the tumor, and brought out at a corresponding point 
at the opposite side. This pin may be entered either above or 
below the horizontal meridian, as appears most convenient to the 
operator. The second pin is then to be introduced at right angles 
to the first, so that they form a cross ( x ). A thread is then passed 
round the staphyloma behind the pins, and tightly tied ; the ends 
may be twisted and fastened to the cheek. Simple cerate dressing 
and a compress bandage should be applied. At the end of the 
third day the protrusion, together with the pins and thread, are 
generally found to be detached, and on the eighth or ninth day the 
wound is firmly cicatrized. If the staphyloma is total or large, as 
little as possible should be included between the pins, and the 
threads should not be drawn too tight, lest the strangulated portion 
might give way, or severe ophthalmitis be set up. In partial! 
staphyloma its whole base should be included, and the threads tied 
close and tight within the remaining cornea. I have had no per- 
sonal experience of this operation, but it has been strongly recom- 
mended by several eminent surgeons, more especially for partial 
staphyloma, as it leaves a good portion of clear cornea, behind 
which to make an artificial pupil. The operation is almost free 
from danger, and leaves, at the worst, a firm moveable stump for 
an artificial eye.' 

13.— INJURIES AND WOUNDS OF THE CORNEA. 

Foreign bodies are frequently met with on the cornea, and amongst 
the most common are chips or splinters of iron, steel, wood, glass, 
etc., Which have become lodged or impacted on the surface, or more 

1 Vide an excellent description of this operation in the French Translation of 
Mackenzie's Diseases of the Eye, vol. iii., 1867. 
11 



162 DISEASES OP THE CORNEA. 

or less deeply in the substance of the cornea. The presence of a 
foreign body on the cornea generally at once excites considerable 
reaction. The eye becomes flushed and painful, and this is accom- 
panied by photophobia and lacbrymation. There is a well-marked 
rosy zone around the cornea, and, on account of the ciliary irrita- 
tion, the pupil is contracted. There is generally no difliculty in 
detecting the presence of a foreign body in the cornea, more especi- 
ally if the former is dark {e.g., a chip of steel or iron), and if the 
eye is turned sideways to the light. But if any doubt exists as to 
the presence and exact situation of a foreign body, atropine should 
be applied, and the eye examined with the oblique illumination, 
and, if necessary, with the aid of a magnifying glass. The ad- 
vantage of employing atropine is, that the dark background afforded 
by the widely dilated pupil throws the cornea into strong relief, 
and thus facilitates the detection of a foreign body, particularly if 
this be light colored, as, for instance, a splinter of glass. 

If the foreign body is situated superficially, and is early removed, 
no trace of its presence may remain. If, however, it has escaped 
detection, or the patient has not sought relief, and the foreign body 
is allowed to remain in the cornea, it may set up very considerable 
corneitis, and even iritis, accompanied, perhaps, with hypopyon. 
The cornea around the foreign body becomes infiltrated, and even 
a more or less extensive ulcer may be formed, or suppurative 
corneitis may supervene, with hypopyon, iritis, and sloughing of 
the cornea. This is often observed in aged and decrepit individuals, 
when a foreign body (e.g., a, portion of wheat ear, a splinter of 
glass) has become impacted in the substance of the cornea. In 
other and rarer instances, a layer of lymph surrounds and encap- 
sules the foreign body, which remains innocuous in the very sub- 
stance of the cornea. Sometimes a splinter of steel or iron passes 
partly through the cornea, and projects somewhat into the anterior 
chamber, lying half in the latter, and half in the cornea. 

There is generally no difficulty in removing chips of steel, iron, 
or glass lodged upon the anterior surface of the cornea, close be- 
neath the epithelial layer. As a rule, I always prefer to keep the 
eyelids apart with the stop speculum, and to fix the eye with a 
pair of forceps. By so doing, we avoid all risk from any sudden 
movement or start of the patient, and can accomplish the removal 
of the foreign body very quickly and efficiently. The application 
of the speculum and forceps undoubtedly causes some degree of 
pain, but this is more than counterbalanced by the advantage of 
having the eye completely under our control. I have but too often 
seen that, after numerous ineffectual and painful attempts to re- 
move the foreign body, they had, after all, to be employed. The 
patient should sit on a chair, either directly facing the light, or if 
the foreign body can be better seen, with the face turned sideways 
towards it, and his head should lean back against the breast of the 
operator, who should stand behind him. lEaving applied the spec- 
ulum, the surgeon steadies the eyeball with a pair of forceps, held 
in his left hand, and endeavors, to remove the foreign body with 



INJURIES AND WOUNDS OF THE CORNEA. 163 

the spud, by passing the instrument behind it and thus lifting it 
out. If the foreign body is impacted deeply in the substance of 
the cornea, there arises the danger that in our endeavors to remove 
it we should push it further in, or cause it to perforate and fall 
into the anterior chamber. A broad needle should in such a case 
be carefully passed behind the foreign body, and thus be lifted out. 
If it lies very near the posterior wall of the cornea, the needle may 
be passed into the anterior chamber and the broad part of its blade 
pressed against that portion of the posterior wall of the cornea which 
is opposite the foreign body, so as to steady this, and then it may 
be removed with another needle, or a very fine pair of forceps. A 
similar proceeding is to be adopted if the foreign body protrudes 
partly into the anterior chamber, for then an iridectomy knife or 
a broad needle should be passed into the latter and pushed behind 
the foreign body, gently pressing this back into the cornea ; its an- 
terior end should be seized with a pair of forceps, and in this way 
it may be readily extracted. If a bit of steel is situated on the 
surface of the cornea, it may also be removed with a magnet. After 
the removal of a foreign body from the cornea, a drop or two of 
castor-oil should be applied to the eye to lubricate the parts. After- 
wards atropine should be applied, in order to allay the irritation. 
If the latter is considerable, and accompanied by severe ciliary 
neuralgia, cold compresses and leeches are indicated, followed by 
warm poppy fomentations. The use of the eyes must be forbidden 
until all symptoms of irritation have subsided. 

The effects which burns, injuries from quicklime, molten lead, 
and chemical agents may have upon the cornea have already been 
described in the section on injuries to the conjunctiva (p. 100), and 
the same course of treatment is to be pursued as was advocated 
there. 

Wounds of the Cornea. — The danger to be feared from these varies 
according to their extent, situation, and nature. It occasionally 
happens that a very superficial cut with a sharp instrument does 
not perforate the cornea, but simply penetrates into its substance, 
and forms a small flap, which may heal readily, by the first inten- 
tion, without leaving any trace. Thus a small, clean cut or punc- 
ture of the cornea frequently heals without leaving any mark behind, 
as is daily evidenced bj v operations upon the cornea, as, for instance, 
those for cataract, either performed with a knife or by the needle. 
The chief danger of penetrating wounds of the cornea is that they 
may cause considerable prolapse of the iris, or that they should im- 
plicate the iris and lens, and thus set up severe iritis of traumatic 
cataract. In such cases the condition not only of the cornea, but 
also of the iris and lens, must be carefully watched, for any impli- 
cation of these structures of course greatly enhances the danger of 
the accident. Bruises of the cornea by blunt instruments also 
often prove very dangerous, as, on account of the contusion of the 
injured part and its vicinity, severe inflammation, perhaps of a 
suppurative character, is set up, which may even lead to suppura.- 
tion of the cornea. 



164 DISEASES OF THE CORNEA. 

In the treatment of injuries or wounds of the cornea the first in- 
dication is to subdue the symptoms of irritation and inflammation. 
If there is great pain, cold compresses should he sedulously em- 
ployed, or a few leeches should be applied to the temple, followed 
by hot poppy fomentations, so that free after-bleeding may be en- 
couraged. A strong solution of atropine should be prescribed, the 
compound belladonna ointment be rubbed over the forehead, and a 
light, though firm compress bandage be applied, in order that the 
parts may be kept perfectly at rest. If the symptoms of inflam- 
mation do not readily yield to such treatment, the eye should be 
again most carefully examined, in order that it may be ascertained 
whether a little foreign body has not remained undetected in the 
cornea, anterior chamber, or iris. The various complications, such 
as prolapse of the iris, iritis, traumatic cataract, etc., must be treated 
according to the general rules laid down in the sections in which 
these affections are described. If an incised wound is situated 
partly in the cornea and partly in the sclerotic, it occurs sometimes 
that the portion in the latter situation does not heal readily, and 
that a little fistulous opening may remain. In such cases, the 
treatment is to unite the wound in the sclerotic by means of one 
or two fine sutures, according to its extent. This will keep the 
lips of the incision in contact, plastic lymph will be effused, and a 
firm union will soon be effected. The thread should carry a needle 
at each end, so that we may be able to insert the suture into the 
sclerotic from within outwards, otherwise a sudden start of the pa- 
tient might cause the point of the needle to penetrate the eye. 

Tumors of the cornea are very rarely indeed met with as origi- 
nating in the tissue of the cornea itself, and almost always pass 
over on to it from the conjunctiva. The dermoid tumor is of most 
frequent occurrence, and has been already described at length in 
the article upon tumors of the conjunctiva (p. 103). Stellwag 1 de- 
scribes a case of primary cancer of the cornea, and a case of epithe- 
lioma of the cornea is reported by Colsman. 2 

1 "Die Ophthalmologic vom naturw. Standp." I. 347. 

2 "Kl. Monatsbl." 1869. 51. 



Chapter III. 
DISEASES OF THE IRIS. 



1.— HYPEREMIA OF THE IRIS. 

Hyperemia of the iris is of far more frequent occurrence than 
is generally supposed. Nor can we be surprised at this, when 
we remember the close connection which exists between the iris 
and cornea on the one hand, and the iris, ciliary body, and choroid 
on the other. Indeed, we may regard the iris as the anterior ter- 
mination of the ciliary body and choroid, the whole forming, in 
reality, one tissue, the uveal tract. Hence the frequency with 
which inflammation of the iris extends to the ciliary body and 
choroid, and vice versd. In a hypersemic condition of the iris, we 
find that there is more or less marked subconjunctival injection ; 
that the pupil is somewhat contracted and sluggish, not reacting 
freely on the application of atropine ; and that the iris is discolored, 
which is due to the increased vascularity imparting a reddish tint 
to the natural color of the iris. Thus a blue iris will become some- 
what green, and a brown iris assume a slight admixture of red. 

All causes which produce congestion of the deeper tunics of the 
eye may excite hyperemia of the iris. Of these the most frequent 
are over-exertion of the eyes in reading, engraving, etc., and in- 
flammatory affections of the choroid, ciliary body, and cornea. 
But this condition may even be produced in acute granular oph- 
thalmia, if this is injudiciously treated by caustics and strong 
astringent collyria. 

The treatment must be chiefly directed towards a removal of the 
cause, and an alleviation of the irritation ; hence, strict and pro- 
longed rest of the eyes should be enforced, and they should also be 
guarded against exposure to strong light, cold, etc. Atropine 
should be applied to diminish the irritability of the eye. 



2— INFLAMMATION OF THE IRIS. 

In iritis there are superadded to the symptoms of hypersemia of 
the iris those of an effusion of plastic lymph at the edge of the 
pupil, or on the surface and into the stroma of the iris. 

Formerly the inflammations of the iris were classified according 
to the dyscrasise of which they were supposed to be pathognomonic, 



166 DISEASES OF THE IRIS. 

and a formidable array of different forms of iritis was in this way 
established. By chiefly basing our classification on pathological 
anatomy, we can, however, greatly simplify the subject, and so 
embrace all shades of iritis within the following four groups: 1. 
Simple idiopathic iritis. 2. Serous iritis (Descemetitis, etc.). 3. 
Parenchymatous iritis. 4. Syphilitic iritis. 

In order to avoid unnecessary repetition, I shall first describe 
the various symptoms which more or less accompany all inflamma- 
tions of the iris, and then call attention to those which characterize 
the special forms. -it 

Amongst the earliest symptom's" of iritis are conjunctival, and 
especially subconjunctival injection, ciliary neuralgia, contraction 
and sluggishness of the pupil, arid a discolored, dull, lack-lustre 
appearance of the iris. 

There is generally some injection of the conjunctiva, which may 
be chiefly confined to the palpebral portion, or extend also to the 
ocular conjunctiva in the vicinity of the cornea. But a far more 
constant symptom is the subconjunctival vascularity, giving rise to 

a more or less broad, rosy zone of 
[Fig. 52. parallel vessels, closely ranged round 

the cornea. [Fig. 52.] This zone is 
generally of a bright rose color, and 
consists chiefly of small arterial twigs. 
It may, however, assume a somewhat 
blue or brownish tint, and the latter 
was formerly erroneously supposed to 
After Pirrie.i be symptomatic of syphilitic iritis. _ Al- 

though marked subconjunctival injec- 
tion is present in the great majority of cases of iritis, we occasionally 
meet with severe cases in which it is not very conspicuous, as in 
typhus fever, pyaemia, etc. There is also more or less chemosis, 
and this may be so considerable that the conjunctiva is raised like 
a red or bluish-red mound round the cornea. The eyelids are often 
also swollen and puffy. In the milder cases they may retain their 
normal appearance, but if the attack is severe, the upper lid gener- 
ally becomes red, glistening, and very cedematous and swollen. 
This is more especially the case in suppurative iritis or irido-cyclitis. 
The intensity of the pain is very variable, for although/ it is 
generally severe, and often extremely so, it may in some cases be 
nearly entirely absent. The patient may at first only experience a 
feeling of itching and burning in the eye, but soon the pain be- 
comes more severe, and assumes a sharp, cutting, lancinating cha- 
racter. It may be chiefly situated deeply in the eyeball, or extend 
to the forehead, temple, and corresponding side of the nose (ciliary 
neuralgia). Sometimes there is very intense neuralgia of the 
branches of the fifth nerve, extending over the corresponding side, 
of the face and head, even as far as the occiput. The pain always 
increases in intensity towards evening, remaining very severe 
during the night, and diminishing towards morning. Although 
the patient may experience very acute pain in iritis, it is important 




INFLAMMATION OF THE IRIS. 167 

to remember that the eye is not painful to the touch in a case of 
simple uncomplicated iritis. If sharp pain is caused when the 
ciliary region is pressed by the finger, it is indicative of the co- 
existence of inflammation of the ciliary body (cyclitis). Very fre- 
quently this tenderness is partial, and confined to the upper portion 
of the ciliary region. 

The severity of the pain may give rise to some constitutional 
disturbance, and the exacerbations be accompanied by feverishness, 
a loaded tongue, impairment of appetite, and a tendency to retching 
and vomiting, which not unfrequently causes the disease to be mis- 
taken for a severe bilious attack. 

Although considerable photophobia and lachrymation may ac- 
company iritis, they are seldom so severe and marked as in certain 
forms of corneitis. 

We now come to the symptoms presented by the iris itself. 
Amongst the earliest are discoloration and dulness of the iris, and 
contraction of the pupil. The discoloration of the iris is partly 
due to hyperemia and partly to an effusion into its structure. In 
order to estimate rightly the changes in color, we must always 
compare the affected with the other eye (if this be sound), other- 
wise an error may easily occur. We must also be upon our guard 
not to mistake the dulness and change in the tint of the iris, which 
may be produced by cloudiness of the cornea and of the aqueous 
humor, as being resident in the iris itself. Besides the discolora- 
tion, the iris presents a ^peculiar dull, lack-lustre appearance, its 
surface having lost its natural bright, glistening aspect, and ap- 
pearing hazy and dull, as if covered by a fine veil. Its nbrillaa 
are also not sharply defined, but indistinct and blurred. This de- 
pends in a great measure upon the hypertrophy of the connective 
tissue elements of the iris, and upon the effusion of lymph into 
the stroma and upon the surface of the iris. 

The pupil is sluggish and more or less contracted. This gener- 
ally occurs in all but the very slightest cases of iritis, or in those 
in which there is a tendency to increase in the intra-ocular tension. 
This immobility of the pupil is partly caused by the hyperemia of 
the vessels, but chiefly by the serous or plastic effusion which has 
taken place into the stroma of the iris, and impedes the action of 
the circular fibres of the iris. If the inflammation is but partial, 
the immobility of the pupil may be the same. In testing the 
mobility of the pupil, the patient should be placed so that the light 
falls sideways upon the eye. The other must be firmly closed with 
our hand, or by a handkerchief. The affected eye is to be shaded 
with the palm of our hand, which is then to be rapidly removed 
so as to admit the light, and the behaviour of the pupil accurately 
watched, so that its size, mobility, and the extent of its contractions 
may be ascertained. It must be remembered that contraction and 
impaired mobility of the pupil may exist without any iritis; for 
they may be seen in corneitis, hypersemia of the iris, or if a foreign 
body is lodged on the cornea, and are in these cases due to irrita- 
tion of the ciliary nerves. 



168 



DISEASES OF THE IBIS. 



The edge of the pupil generally soon loses its circular form and 
becomes somewhat irregular [Fig. 53], and we may notice along it 
small exudations or beads of plastic lymph, which tie it down to 
the anterior capsule. These may, however, be so minute as to 
escape detection, until the pupil is examined with the oblique illumi- 
nation, or atropine is applied. The individual exudations often 
increase in size and coalesce, and, more lymph being effused, the 
whole circumference of the pupil may become fringed with them, 
and be tied down to the capsule of the lens, the centre of the pupil 



[Fig. 53. 




After T. W. Jones. 




After Lawrence.] 



perhaps remaining clear and thus still permitting of good vision. 
This condition is termed " circular" or " annular" synechia, or 
" exclusion of the pupil." "We must distinguish this from the condi- 
tion in which the effusion invades the area of the pupil, so that a 
more or less considerable portion of it is covered by a film of lymph, 
or even the whole of it occluded by a thick nodule of exudation, 
the sight being of course proportionately deteriorated ; this is called 
" occlusion" of the pupil. [Fig. 54.] The exudation of lymph 
between the iris and the capsule of the lens is not always limited 
to the edge of the pupil, but may extend further back along the 
posterior surface of the iris, and thus produce broad and very firm 
adhesions. We shall see hereafter, that this fact is of great import- 
ance in the performance of iridectomy for chronic iritis or irido- 
choroiditis. The partial adhesions between the pupil and capsule 
vary greatly in thickness, extent, and number, and become very 
apparent when atropine is applied, as they then give rise to various 
irregularities in the shape of the pupil. 

The surface of the iris may become covered with a film of exuda- 
tion, or the lymph may mix with the aqueous humor and render 
this turbid and clouded; or it may be precipitated against the 
posterior wall of the cornea in the form of small whitish opacities ; 
or again, it may sink to the bottom of the anterior chamber, where 
it collects in the form of an hypopyon. The amount of this 
yellowish deposit varies ; it may be so slight as easily to escape 



INFLAMMATION OF THE IRIS. 169 

detection, appearing simply like a small yellow fringe along the 
lower edge of the anterior chamber ; or it may attain such a size, 
that it fills half or even more of the anterior chamber. 

In simple iritis the cornea is generally quite transparent, or 
shows but the faintest amount of cloudiness. Small portions of 
lymph may, however, be deposited from the aqueous humor upon 
the posterior wall of the cornea, giving rise to a punctated appear- 
ance. This occurs especially in the serous form of iritis. But the 
cornea may, also, become implicated in the inflammatory process. 

Vision is often considerably impaired. This may be partly due 
to the cloudiness of the aqueous humor and of the area of the pupil. 
If the sight is much affected and the pupil not occluded, we must 
suspect the coexistence of cyclitis, which is often accompanied by 
diffuse opacity of the vitreous humor. The power of accommoda' 
tion is then, moreover, also affected. It is, therefore, very necessary 
accurately to test the degree of vision at the commencement of an 
iritis, in order that we may at once detect any marked deteriora- 
tion, and ascertain to what cause this is due. The tension of the 
eyeball is normal in a case of common iritis, and the field of vision, 
although it may be somewhat contracted on account of the small- 
ness of the pupil, or the presence of synechise, does not show the 
contraction peculiar to a glaucomatous condition of the eye. 

We must now consider the symptoms by which the special forms 
of iritis are characterized. 

1. The Simple Idiopathic Iritis is sometimes very slight in degree, 
and accompanied by only a very moderate amount of subconjunc- 
tival injection, photophobia, pain, or discoloration of the iris ; 
indeed, its existence may remain quite unsuspected until atropine 
is applied, when the pupil is found to be irregular, and shows here 
and there a slender adhesion to the capsule. [Fig. 55.] 

This mild form of iritis is often met with after opera- [Fig. 55.] 
tions upon the eye {e. g., cataract operations), or after 
injuries. The affection may, however, be more severe, 
and there is much pain, swelling of the lids, injection of 
the conjunctiva and subconjunctival tissue, chemosis, 
photophobia, and lachrymation. The iris is discolored, 
the pupil contracted and inactive, having deposits of lymph at its 
edge and perhaps also in its area. A film of exudation covers the 
surface of the iris, rendering it dull and hazy, the aqueous humor 
is somewhat turbid, and the posterior surface of the cornea perhaps 
mottled with small deposits of lymph. 

2. Serous Iritis (syn. Descemetitis, aquo-capsulitis, keratitis punc- 
tata, etc.) is chiefly distinguished by the absence of plastic exuda- 
tion, and by the great tendency to hypersecretion of the aqueous 
humor. The symptoms of acute iritis are generally not very 
pronounced. The aqueous humor is secreted in greater quantity, 
and is somewhat clouded and turbid, and on closer observation we 
can often notice small particles of lymph floating about in it, before 
becoming deposited on the posterior surface of the cornea, or at the 
bottom of the anterior chamber. The latter is often markedly 




170 



DISEASES' OF THE IKIS. 



[Fig. 5G 




deepened, and the cornea appears somewhat bulged forward. The 
cloudiness of the aqueous humor often varies considerably and 

rapidly within the course of a few 
hours. The cornea may at first 
appear abnormally brilliant, but 
it soon loses its lustre and becomes 
slightly clouded, and small punc- 
tated opacities make their appear- 
ance upon its posterior surface. 
[Fig. 56.] These may be situated 
opposite the pupil, being perhaps 
grouped in a small circle ; but they 
'^^MppSJIpF are generally arranged in the form 

, f :!! 0^ of a pyramid, the base of which is 

After Dairympie.j turned towards the periphery of the 

cornea, and its apex towards the 
centre; the smaller opacities being situated at the apex and the 
larger and coarser ones at the base. This proves that the opacities 
are composed of small masses of lymph, deposited from the aqueous 
humor upon the posterior wall of the cornea, and that they arrange 
themselves according to their size and weight, the larger and 
heavier ones gravitating downwards. The truth of this assertion 
has moreover been proved experimentally by Arlt. 1 He placed the 
head of the patient in different directions, sometimes keeping it for 
a length of time turned to the right side, sometimes to the left, and 
he found that the ba.se of the pyramid always corresponded to the 
side of the eye which had been maintained in the lowest position. 
But some of the opacities met with at the posterior portion of the 
cornea, are not due to these deposits from the aqueous humor, but 
are caused by inflammatory changes in the epithelial layer, or even 
in the posterior portion of the cornea proper. 

The iris is but slightly discolored, and the pupil, instead of being 
contracted, as is generally the case in iritis, is somewhat dilated, 
often markedly so. This is due to an increase in the intra-ocular 
tension, which is often present in this disease, and the manifesta- 
tion of which must be watched with the greatest care, for this 
serous form of inflammation shows a great tendency to extend to 
the ciliary body and choroid, which is accompanied by hyper- 
secretion of the vitreous humor, marked increase in the intra-ocular 
tension, and a glaucomatous condition of the eye. The degree of 
eye tension, the state of the sight and of the field of vision must, 
therefore, be frequently and carefully examined during the course 
of the disease, in order that the earliest symptoms of a glaucomatous 
complication may be detected and at once arrested. Adhesions 
between the edge of the pupil and the capsule are not of frequent 
occurrence in this form. 

Serous iritis occasionally accompanies deep-seated inflammations 
of the eye, more especially chronic irido-choroiditis, and choroido- 



Auarenlienkunde, II. 45. 



INFLAMMATION OF THE IRIS. 171 

retinitis. Moreover, sympathetic ophthalmia sometimes appears 
in the form of serous iritis. It has also been supposed to be due 
to constitutional or hereditary syphilis. 

3. Parenchymatous Iritis. — In this affection the inflammation 
attacks the tissue of the iris, and its fibrillse become much swollen 
and thickened. The plastic exudation is poured out into the paren- 
chyma of the iris, along the edge and into the area of the pupil, 
and also on the posterior surface of the iris, giving rise to thick 
broad adhesions between it and the capsule of the lens. On account 
of the exudation into the stroma of the iris, and the swollen and 
thickened condition of its fibrillse, the circulation is generally con- 
siderably impeded, and large tortuous veins make their appearance 
on its surface. Along the edge of the contracted pupil are noticed 
a number of thick, firm nodules of exudation, of a creamy or red- 
dish-brown color, tying down the edge of the pupil to the capsule ; 
or they may even extend around the whole edge of the pupil, and 
thus give rise to a circular synechia (exclusion of the pupil). The 
effusion generally also invades the area of the pupil, indeed the 
latter may be. completely blocked up by a thick yellow nodule ot 
purulent exudation.- The surface of the iris appears indistinct and 
hazy, its fibrillse are swollen, and its anterior surface is covered by 
a layer of exudation, which varies considerably in appearance. In 
some eases, it looks simply like a thin gray veil covering different 
portions or even the whole of the iris, in others, it assumes a thick, 
creamy, purulent appearance, with small extravasations of blood 
scattered about here and there. Little yellow nodules (which are 
not to be confounded with the syphilitic ' tubercles) may also 
appear strewn about on the surface of the iris. On account of the 
detachment of some of these nodules, and the effusion of lymph 
and purulent exudation into the aqueous humor, the latter becomes 
turbid and discolored. .Flakes of purulent lymph and globules of 
pus are seen floating about in it, and sinking down, give rise to au 
hypopyon, which may be so small as to appear only like a narrow 
yellow belt along the lower edge of the anterior chamber, or may 
be so considerable as to occupy one-half or more of the anterior 
chamber, reaching perhaps above the upper edge of the pupil. This 
parenchymatous or suppurative iritis, may be accompanied by a 
similar form of inflammation of the ciliary body and choroid. 

4. Syphilitic Iritis generally assumes the parenchymatous form. 
It is, however, especially characterized by the formation of peculiar 
tuberculous nodules (gummy tubercles, Virchow). These are scat- 
tered about singly over a certain portion, or even the whole, of the 
surface of the iris, in the form of yellowish-red condylomatous 
nodules. They appear at first deeply imbedded in the parenchyma 
of the iris . (originating in the deeper portion of its connective 
tsssue), and as they increase in size, they push aside the fibi-illse of 
the iris, and protrude between them into the anterior chamber. 
They may attain a very considerable magnitude, their apex even 
touching the posterior wall of the cornea. They (according to 
Colbert) exactly resemble in structure the gummy tubercles (gum- 



172 DISEASES OF THE IRIS. 

mata) of Virchow. On account of the presence of pigment cells,- 
and the great vascularity, the nodules frequently assume a dark 
reddish-brown sarcomatous appearance. They often undergo fatty 
and purulent degeneration, breaking down into a yellow, grumous, 
purulent mass, which becomes mixed with the aqueous humor. 
They may, however, undergo rapid absorption. These tubercles, or 
condylomata as they are sometimes called, frequently remain con- 
fined to one portion of the iris, in which the inflammatory changes 
are moreover also more pronounced, so that the disease assumes a 
somewhat partial character, which is peculiar to the syphilitic form. 
We find, in such cases, that, although the whole cornea may be 
surrounded by a pink zone of vessels, this is most conspicuous at 
one point, and that the corresponding segment of iris is the most 
thickened and swollen, and that the condylomata are chiefly or 
entirely confined to this portion. 

It must be distinctly remembered that, although the name of 
syphilitic iritis is given to the form of inflammation above described, 
the iritis which may occur in the course of, and be entirely due to, 
syphilis, does not necessarily always assume this type. For it may 
appear as a simple idiopathic iritis, or in a more or less severe paren- 
chymatous form, so that the absence of the peculiar gummy tuber- 
cles does not exclude the presence of syphilis in the system, or its 
being the cause of the iritis. But, on the other hand, the existence 
of these tubercles may, in the vast majority of cases, be taken as a 
certain indication of the syphilitic nature of the inflammation: I 
can only remember having seen one case (a patient of Mr. Critch- 
ett's) in which there were well-marked tubercles without the 
slightest evidence of syphilis. Some authors have stated that in 
syphilitic iritis the circumcorneal zone of injection is of a brownish 
tint, and that the pupil is displaced upwards and inwards. This 
is, however, not the case, for both these appearances may be met 
with apart from syphilis. 

Amongst the causes of iritis, a very frequent one is exposure to 
sudden changes of temperature, cold draughts of air, rain, wind, etc. 
The disease is, in such cases, often termed rheumatic iritis. It may 
also accompany rheumatism in other parts of the body, being evi- 
dently produced by the same cause. It is erroneous, however, to 
speak of rheumatic iritis as a special form of the disease, for it has, 
in truth, no characteristic symptoms ; it generally assumes the form 
of simple iritis, and may vary greatly in severity, but is not, as a 
rule, accompanied by extensive exudative changes in the paren- 
chyma of the iris, or by considerable hypopyon. The pain is fre- 
quently extremely severe, and may extend over the corresponding 
side of the head and face. The disease often runs a chronic and 
very protracted course, and relapses may take place on a recurrence 
of the rheumatic attack. 

Iritis is also often of traumatic origin, being caused by mechanical 
or chemical injuries, which either affect the iris directly or secon- 
darily. Thus foreign bodies may remain lodged for some time in 
the conj unctiva, cornea, anterior chamber, or in the deeper tunics 



INFLAMMATION OF THE IRIS. 173 

of the eye, and then set up iritis. Clean incised wounds of the iris 
are not prone to give rise to it, as is proved by the operation of 
iridectomy, nor does strangulation or compression generally do so, 
as is evidenced by iridodesis. Wounds which bruise and lacerate 
the iris are the most apt to set up iritis. Injury of the lens, fol- 
lowed by traumatic cataract, very often produces it, more especially 
if the iris has been implicated in the injury, or the lens swells up 
very considerably and presses upon the iris. It also often super- 
venes secondarily upon other inflammations of the eye. Thus cor- 
neitis, especially the diffuse and suppurative forms, and deep or 
perforating ulcers of the cornea, are frequently accompanied by 
iritis ; this is still more the case in inflammation of the choroid 
and ciliary body. 

Syphilis is a very frequent cause. When primaiw iritis occurs in 
infants or young children, it is almost always due to syphilis, and 
in such cases we generally meet with other symptoms pathogno- 
monic of the syphilitic taint, such as condylomata about the anus, 
specific eruptions, etc. In adults it but seldom occurs together 
with the primary symptoms, but generally during the secondary or 
tertiary stage, being often the precursor of these symptoms, when 
the primary have disappeared. The iritis frequently occurs simul- 
taneously with the syphilitic eruptions of the skin. 

Some authors have asserted that gonorrhoea is sometimes the 
cause of iritis. Thus, Mackenzie 1 describes a special form, under 
the name of "gonorrhceal iritis." Mr. Wordsworth 2 has also nar- 
rated three cases in which iritis occurred together with gonorrhoea. 
It must, however, be stated that all three were complicated with 
rheumatism. I have myself never met with a case of iritis asso- 
ciated with gonorrhoea alone ; but have only observed it in cases 
in which gonorrhoea coexisted with syphilis or with rheumatism, 
either of which diseases, as I have already stated, is a frequent cause 
of iritis. Nov does the so-called " gonorrhceal iritis" present any 
special or pathognomonic features. 

Sympathetic inflammation of the iris is apt to occur after injuries 
to the eye, or the lodgment of a foreign body within it, etc. The 
sympathetic iritis may assume the serous character, but generally 
appears in the form of suppurative irido-choroiditis. ( Vide article 
on " Sympathetic Ophthalmia.") 

Chronic Iritis is especially distinguished by the fact that the in- 
flammatory symptoms are generally but slightly marked, or are 
almost so entirely absent that the patient is not aware that there 
is anything the matter with his eye, except a slight weakness or 
" cold" in it, as he frequently expresses it. The ocular conjunctiva 
and subconjunctival tissue are but slightly injected; there is only 
a faint pink blush around the cornea ; there is but little photo- 
phobia, lachrymation, or ciliary neuralgia. The pupil is somewhat 
contracted and sluggish, and, at certain points, perhaps immoveable. 
On examining it with the oblique illumination, we may frequently 

1 "Mackenzie on Diseases of the Eye," 552. * " R. L. 0. H. Rep.," iii. 301. 



171 DISEASES OF THE IKIS. 

notice small adhesions between the edge and the capsule, which, as 
well as the irregularity of the pupil, become very evident upon 
the application of atropine. The color of the iris becomes gradu- 
ally more changed, and this alteration in its tint is permanent, 
whereas in acute iritis it passes off again with the subsidence of 
the disease, without, perhaps, eventually leaving any trace behind. 
The normal brightness and lustre of the iris become faded and 
dulled, its fibrillse indistinct and obliterated, and in the later stages 
of the disease it presents a yellowish-gray, dirty-brown, or slate- 
colored appearance, its tissue being thinned and atrophied, and 
traversed, perhaps, by enlarged and somewhat tortuous bloodvessels. 
The presence of such dilated vessels always indicates a state of 
congestion and stasis of the circulation in the iris and ciliary body. 
At this advanced stage, the iritis is generally, however, no longer 
simple in character, but has become complicated with inflammation 
of the ciliary body and choroid. ( Vide tbe article on " Irido- 
choroiditis.") 

Chronic iritis may supervene upon a more acute form of iritis, or 
the disease may manifest this chronic and insidious character from 
the very outset. It also frequently accompanies inflammations of 
the cornea, more especially the diffuse corneitis. Relapses are very 
apt to occur in chronic iritis ; these recurrent inflammatory exacer- 
bations being often produced by very slight causes, such as undue 
use of the eyes, particularly by artificial light, exposure to cold, 
wet, etc. This tendency to recurrence is especially marked in those 
cases in which numerous or extensive posterior synechias exist. 
For their presence is a constant source of irritation and teasing, as 
they prove a check to the free, spontaneous movements of the pupil, 
and in such cases a slight cause will suffice to rekindle the inflam- 
mation. During the recurrence of the inflammation, fresh lymph 
will be effused, and the posterior synechias will increase still further 
in number and firmness, until finally, after perhaps frequent re- 
lapses, the whole circumference of the pupil is firmly tied down to 
the capsule, and the communication between the anterior and 
posterior chamber is completely interrupted. It will be seen here- 
after that such an exclusion of the pupil (circular synechia) is one 
of the most frequent causes of irido-choroiditis. 

The prognosis of iritis will depend very much upon the severity 
and the cause of the inflammation. If the disease be seen at a very 
early stage, before any adhesions have been formed between the 
edge of the pupil and the capsule of the lens, or whilst these are 
yet so slight and brittle as to be readily torn through by the ener- 
getic use of atropine, the prognosis is in every way very much 
more favorable, than if numerous firm posterior synechias have 
already been established, and resist the action of atropine. Paren- 
chymatous and syphilitic iritis afford a less favorable prognosis 
than the simple or the serous form, as they are generally accom- 
panied by very considerable exudations of lymph at the edge of the 
pupil, on the surface and into the structure of the iris, and into 
the anterior chamber. The tendency to implication of the cornea, 



INFLAMMATION OF THE IRIS. 175 

or the deeper tunics of the eyeball must also be borne in mind. In 
traumatic iritis, the nature and extent of the injuiy, the presence 
of traumatic cataract, or the coexistence of inflammation of the 
ciliary body or choroid must all be taken into consideration in 
framing the prognosis. 

Treatment. — The patient should be carefully guarded against the 
injurious influences of bright light, and sudden changes of tempe- 
rature, as well as cold -and wet. Perfect rest of both eyes must 
also be enjoined, and if the patient has to leave the house, a 
bandage should be placed over the affected eye, and a shade over 
the other, or goggles should be worn. But if the disease is very 
severe, strict orders must be given that the patient is to keep in a 
darkened room. We are, however, very frequently obliged to treat 
even severe cases of iritis as out-patients, and may, even, in such 
instances frequently succeed in effecting an excellent cure. This 
mode of treatment should however only be adopted from necessity, 
and not from choice, and strict injunctions should be given to the 
patients to guard their eyes as much as possible against all noxious 
influences during the intervals of their visits. 

The point of the very greatest importance in the treatment of 
iritis is to obtain a wide dilatation of the pupil as soon as possible, 
and hence a strong solution of atropine should be at once ener- 
getically applied to the eye. The beneficial effect of atropine is 
three-fold: 1. "Wide dilatation of the pupil is produced, and the 
iris is, therefore, removed from the contact with the anterior cap- 
sule of the lens, so that no adhesions can be formed between them 
at theedge of the pupil, or on the posterior surface of the iris. Thus 
one of the chief dangers of iritis, the formation of extensive pos- 
terior synechise, is prevented, and the numerous evil consequences 
or dangerous complications to which they may give rise, are ob- 
viated. 2. Rest will be afforded to the inflamed muscular tissue 
of the iris by a wide dilatation of the pupil ; for if the constrictor 
pupillre is not paralyzed, its constant action in endeavoring to re- 
gulate the size of the pupil according to the stimulus of light, must 
of necessity tend to increase the inflammation, just as would be 
the case in any other inflamed muscular tissue, if this could not 
be kept perfectly at rest. 3. The tension of the eye will be dimin- 
ished, and the intraocular circulation relieved, which will diminish 
the state of congestion of the iris and ciliary body. Moreover, the 
irritation of the eye and the ciliary neuralgia will generally be 
alleviated in a very marked manner. It is, however, absolutely 
necessary that the solution of atropine should be of a sufficient 
strength, and should be energetically employed. In the normal 
condition of the eye, an extremely weak solution (gr. j — gviij of 
water) will suffice to produce a wide dilatation of the pupil, but in 
iritis it is very different. On account of the inflamed and swollen 
condition of the tissue of the iris, of the lymph effused into its 
meshes, and of the hyperemia, great resistance is offered to the 
action of the atropine ; hence a very strong solution must be used, 
and the application repeated very frequently, before we can tho- 



176 DISEASES OF THE IRIS. 

roughly overcome this resistance. I am in the habit of employing 
a solution of from four to six grains of atropine to the ounce of 
water, and of applying it at the interval of five minutes for half an 
hour at a time, this being repeated, if necessary, three or four times 
a day ; so that altogether the atropine may have to be applied from 
eighteen to twenty-four times a day, in order to produce and main- 
tain a sufficient dilatation of the pupil. If the case is seen early, 
before any adhesions, or only very slight and brittle ones, are 
formed, we may generally succeed in producing a wide dilatation 
at the end of a few hours, and then it is not difficult to maintain 
it. I find that patients apply the atropine with much greater 
regularity and exactitude, if they are told to use it for half an hour 
at a time, at intervals of five minutes, and to repeat this at stated 
periods three times a day, than if they are only directed in general 
terms to apply it fifteen or eighteen times a day. As we have fre- 
quently at the hospital to treat even severe cases of iritis as out- 
patients, I invariably apply the atropine myself at the interval of 
a few minutes, until either a decided effect has been produced upon 
the pupil, or the result is negative. In the former case, the patient 
will himself experience the great relief to the pain and irritability 
of the eye which has been produced by the instillations, and will 
readiby and gladly carry out the treatment with regularity at home. 
Moreover, the dilatation thus effected can generally be maintained 
until the next visit, even if the remedy is not applied in the 
interval quite as frequently as directed. I have often been able to 
treat even severe cases of iritis with great success by this simple 
means, without the employment of almost any other remedy, ex- 
cept perhaps the use of warm poppy fomentations ; the result being 
a perfectly circular pupil without any, or only the slightest, adhe- 
sions. I would again, therefore, urge in the very strongest terms 
the energetic use of atropine in iritis, a line of treatment at present, 
unfortunately, but too much neglected in English ophthalmic 
practice, the evil results of which neglect are constantly evidenced 
by the numerous cases of recurrent iritis, chronic irido-choroiditis, 
etc., which we but too frequently meet with, and which might 
have been to a very great extent prevented by the early and effi- 
cient use of atropine. It is quite useless to prescribe a weak solu- 
tion of atropine (gr. ss— j ad gj) to be used a few times in the course 
of the day ; this cannot produce a dilatation of the pupil when the 
tissue of the iris is inflamed, its effect will be nil, as can be easily 
seen by watching the state of the pupil in cases where such weak 
solutions are employed. 

But we sometimes find that the action of even a strong solution 
of atropine, frequently^ applied, is resisted, and that it produces 
little or no effect, and increases rather than diminishes the irrita- 
bility of the eye. In such cases, its use must be desisted from until 
the irritation is relieved by the application of a few leeches to the 
temple, or perhaps by paracentesis of the anterior chamber. This 
relief of the inflammatory irritation and intra-ocular tension, per- 
mits of a freer absorption through the cornea, and hence the effect 



INFLAMMATION OF THE IRIS. 177 

of the atropine will now be often very marked and rapid. This 
effect, as Von G-raefe has pointed out, is sometimes noticed without 
the reapplication of the remedy. Thus atropine may have been 
applied in cases of iritis or corneitis without producing any dilata- 
tion of the pupil, but many hours afterwards this has ensued after 
the application of leeches. "We sometimes notice, also, that al- 
though dilatation of the pupil may have been produced, yet that it 
cannot be thoroughly maintained, the atropine appearing to lose 
its effect. In such cases, it will be found that this is likewise due 
to the great irritation of the eye and the increase in the intra-ocular 
tension, which prevent the absorption of the remedy through the 
cornea. Whereas after the application of leeches or the perform- 
ance of paracentesis, the atropine will again regaiu its power over 
the iris. I need hardly mention, that if the pupil is firmly tied 
down by numerous and thick adhesions, the atropine should be 
applied only in moderation, in order to soothe the irritability and 
diminish the tension of the eye. But if the posterior synechias are 
of recent origin, and not very broad and firm, but narrow and 
tongue-like, the long-continned use of atropine succeeds in tearing 
them through. It is often found, however, that when this remedy 
is employed for a considerable length of time, it increases, instead 
of allaying, the irritability of the eye, and may even induce con- 
junctivitis or acute granulations. The latter are, however, less 
frequently met with, than a vascular condition of the lids, accom- 
panied by swelling of the conjunctiva and great irritation of the 
eye. In such cases, the atropine must be stopped at once, and a 
mild astringent collyrium substituted for it. The strength and 
nature of the latter must vary with the degree of .conjunctivit'is. 
A solution of gr. j of alum, zinc, or nitrate of silver to the ounce 
of water will be found the best. In vesicular granulations a col- 
lyrium of from vj to x grains of borax to 1 ounce of water proves 
of much service. The irritability of the eye may also be allayed 
and the dilatation of the pupil tolerably maintained by the use of 
a collyrium of belladonna (Ext. bellad. 3ss, Aq. dest. gj), which is 
to be applied frequently in the course of the day. It is sometimes 
found that posterior synechias, which resist the action of atropine, 
soon tear through upon the application of Calabar bean. Hence 
this remedy may be tried alternately with the atropine. 

The use of atropine is to be continued even for some weeks after 
the subsidence of the iritis, so that the wide dilatation of the pupil 
may be maintained and the iris be kept in a state of rest. It has 
been urged by some, that the long-continued use of a strong solu- 
tion of atropine is apt to produce a permanent dilatation of the 
pupil from paralysis of the sphincter pupillse. But this is a most 
rare and exceptional occurrence, and if any tendency to dilatation 
should remain, it may be easily overcome by the occasional use of 
the Calabar bean, which excites the action of this muscle. Although 
I am in the habit of using atropine most extensively in the treat- 
ment of iritis and other affections of the eye, I have never met with 
a caBe in which this condition of permanent dilatation was pro- 
12 



178 DISEASES OF THE IBIS. 

duced, nor have I ever observed a case of poisoning from the exces- 
sive use of atropine. Such cases do, however, sometimes occur, and 
'are evidently produced by the passage of the atropine through the 
lachrymal puncta to the throat. The principal symptoms of 
poisoning by atropine are : great increase in the frequency of the 
pulse, dryness of the throat, dysphagia, great irritability of the 
bladder and genital organs, impairment of memory, hallucinations, 
and exciting dreams. The pupils of the eyes are very widely 
dilated. Generally, these symptoms are only moderate in character 
when the poisoning has occurred in the mode above described, but 
their severity is very great if the atropine has been swallowed by 
mistake, and a considerable dose has thus been taken. The best 
and most rapid antidote is the subcutaneous injection of morphia 1 
(gr. £ or J of a grain), to be repeated, if necessary — even several 
times — at intervals of a few hours. The effect of the remedy is 
very marked and rapid ; within a few minutes the violence of the 
symptoms has greatly subsided, and the patient is calm and quiet. 
To avoid the danger of poisoning, when strong collyria of atropine 
are used with great frequency, Von Graefe recommends the patient 
to close the eye directly after the application, and subsequently on 
reopening the eye to wash it well. He also sometimes employs a 
subcutaneous injection of morphia at night, in order to prevent all 
risk. Liebreich 2 has devised a small instrument, like a serre-iine, 
which is attached to the lower punctum, and this produces a slight 
ectropium of this part of the lid, thus preventing the entrance of 
the atropine into the punctum. 

I have already stated that we occasionally meet with persons 
whose eyes show an extraordinary antipathy to the use of atropine, 
and in whom even a drop of a very weak solution suffices to pro- 
duce great irritation of the eye, and perhaps severe erysipelas of 
the lids and face. In such cases it should be stopped at once. My 
friend Dr. Seeley of Cincinnati has informed me that he has found 
in such idiosyncrasies much benefit from combining the atropine 
with a weak solution of sulphate of zinc. 

The severe ciliary neuralgia which so often accompanies iritis is 
most relieved by the application of leeches to the temple, and the 
use of hot poppy or laudanum fomentations. The leeches should 
be applied towards evening, so that the nocturnal exacerbations 
may be relieved. Free after-bleeding is to be encouraged by the 
use of hot fomentations or poultices. The nocturnal pain and rest- 
lessness of the patient are also, much alleviated by the use of opium, 
and this remedy should never be omitted in such cases, as it is of 
much consequence that the patient should enjoy a good night's 
rest. I myself often employ the subcutaneous injection of morphia 
for this purpose. 

A blister may be applied behind the ear, and kept open for a few 

1 Vide Dr. Bell, Edin. Med. Chir. Society, 1867, and Von Graefe's Article, 
"A. f. 0.," ix. 2, 70 ; also a very interesting caseof severe Poisoning by Atropine, 
reported by Dr. Schmid, "Kl. Monatsbl.," 1864, p. 158. 

* "Kl. Monatsbl.," 1864. 411. 



INFLAMMATION OF THE IRIS. 179 

days, and the compound belladonna ointment should he rubbed into 
the forehead. 

If there is a considerable tendency to exudation of lymph or pus 
at the edge of the pupil, so that atropine does not act on the latter, 
into the anterior chamber, on the surface of the iris or into its 
structure, the patient should be got rapidly under the influence of 
mercury. One grain of calomel in combination with one-fourth or 
one-fifth of a grain of opium should be given every two or three 
hours, until salivation is produced, which will generally occur in 
from 30 to 40 hours ; even when this is produced, a slight degree 
of tenderness of the gums should be maintained. I, however, 
greatly prefer the treatment by inunction, as the digestive powers 
are thus not impaired, and the constitutional effects of the drug are, 
moreover, more rapidly and surely obtained. Indeed I have met 
with instances in which mercury had been given by the mouth for 
some time without producing any constitutional effect, and where 
this rapidly supervened upon inunction. Half a drachm or a 
drachm of the strong mercurial ointment should be rubbed into the 
inside of the arms and thighs two or three times daily, until the 
mouth becomes slightly affected, the gums showing an indication 
of the bluish line ; when it is to be applied once daily in much 
smaller quantity. In order to prevent the staining of the skin, the 
ointment may also be rubbed into the bottom of the feet, but here 
it is absorbed with less rapidity on account of the greater thickness 
of the skin. Mr. Pridgin Teale 1 recommends that the mercurial 
ointment should be smeared on a broad piece of flannel which is to 
be wrapped round each arm of the patient, who should remain in 
bed ; a small quantity of fresh ointment being added every night. 
In syphilitic iritis, with well-marked buttons, the use of mercury 
should never be omitted, and I have also found much benefit in 
such cases from the constant use of hot water compresses, continued 
without intermission night and day for several days. I first saw 
this mode of treatment employed two years ago, by Dr. Wecker r 
and soon afterwards had the opportunity of trying it in a case of 
syphilitic iritis with numerous condylomata of considerable size,. 
which had to a great extent resisted the action of mercury. I 
ordered hot water compresses to be applied to the eye of as high a 
temperature as the patient could bear, and these were changed every 
few minutes, and continued for a great part of the day and night. 
Within the course of two days the condylomata had diminished 
considerably in, size, and within four or five days they had almost 
entirely disappeared. In another instance, the effect of the com- 
presses was equally favorable. Of course it is only in exceptional 
cases that this mode of treatment can be employed, for it requires 
the constant and undivided attention of a nurse; moreover, few 
patients will submit to the trouble and inconvenience. This 
remedy also greatly hastens the absorption of hypopyon. 

1 Vide Mr. Teale'a interesting paper " On the Relative Value of Atropine and 
of Mercury in the Treatment of Acute Iritis." "R. L. O. H. Reports," V. 156. 



180 DISEASES OP THE IRIS. 

Formerly it was very much the custom to place all cases of iritis 
under the influence of mercury, quite irrespective of the fact whether 
the necessity for its use really existed or not. ]STow, however, a 
more rational mode of treatment obtains, and mercury is only used 
in those cases in which there is much effusion of lymph. In specific 
cases, the iodide and bromide of potassium, together with the de- 
coction of bark, should be administered after the use of mercury. 
Whilst the latter remedy is being employed, it is also wise to main- 
tain the patient's strength by the use of tonics, more especially 
preparations of steel and quinine. 

In the rheumatic form of iritis, benefit is often experienced from 
the use of oil of turpentine internally, as was first recommended 
by Dr. Carmichael. Although I have often employed it with ad- • 
vantage, I have frequently been obliged to give up its use on 
account of the derangement of the stomach which it produces. It 
should be given in doses of from half a drachm to one drachm two 
or three times daily, made into an emulsion, to which a little car- 
bonate of soda is added to prevent the derangement of the digestive 
organs. Mr. Pridgin Teale uses this remedy very extensively in 
corneo-iritis, as well as in low forms of iritis or corneitis, and 
speaks most strongly in its favor. 

If the aqueous humor is very cloudy, or a considerable hypopyon 
is formed, paracentesis should be performed and, if necessary, re- 
peated several times. The same should be done if the pain is very 
severe and does not yield to the usual remedies. The broad needle 
should be very slowly removed from the anterior chamber, so that 
the escape of the aqueous humor may not be very sudden, otherwise 
there may occur great fiypercemia ex vacuo of the inner tunics of the 
eye. In order to facilitate the escape of the stringy portion of 
lymph, the needle should be slightly tilted sideways, so as to cause 
the section to gape, or the same may be done with a small curette 
or probe. 

But if the iritis is very intense and obstinate, resisting all our 
remedies, and more especially if the sight is much impaired, if the 
synechise are numerous and firm, or there is complete exclusion of 
the pupil, and if the intra-ocular tension is markedly increased, a 
large iridectomy should be made at once. I have often seen this 
produce the most striking benefit, and it must be remembered that 
if the adhesions between the pupil and capsule are at all conside- 
rable and broad, or there is occlusion of the pupil from deposit of 
lymph within its area, an iridectomy will subsequently be neces- 
sary, and the condition of the eye will in all probability be much 
worse when the inflammation has. run its course ; and "hence the 
result of an iridectomy be far less favorable than if it had been 
made at an earlier period, before the changes of structure had 
attained any considerable degree. Moreover,'the iridectomy gene- 
rally acts as the best antiphlogistic, the inflammation, which had 
before resisted all our remedial measures, rapidly subsiding after 
the operation. 

In iritis serosa much benefit is often experienced from exciting 



FUNCTIONAL DISTURBANCES OF THE IRIS. 181 

the free actiqn of the skin and kidneys by diaphoretic and diuretic 
remedies. Atropine should also be applied, as well as a suppu- 
rating blister behind the ear ; but it must be confessed that local 
remedies often prove of little avail. The state of the intra-ocular 
tension, of the sight, and of the field of vision must be narrowly 
watched, and if symptoms of glaucoma supervene, no time should 
be lost in making a large iridectomy. 

The treatment of traumatic iritis must vary according to the 
nature of the injury. If a foreign body has become implanted in 
the iris, it must be carefully extracted, with or without the ex- 
cision of the corresponding segment of the iris. If the lens has 
also been injured and a traumatic cataract has been formed, linear 
extraction, perhaps combined with iridectomy, should be at once 
performed if the lens becomes much swollen, sets up great irrita- 
tion, or the intra-ocular tension is increased. If a portion of the 
iris prolapses through a small wound in the cornea, it should be 
pricked, so that the aqueous humor may flow off, and the collapsed 
protruding portion of iris should then be excised, and a firm com- 
press applied. After an injury to the iris, the inflammation should 
be combated, according to circumstances, by cold or hot compresses, 
leeches, and atropine ; and, if necessary, rapid salivation should be 
induced. 

In order to prevent, if possible, the recurrence of the inflamma- 
tion, more especially in cases of chronic iritis, the patients should 
be warned against undue exposure to cold winds, draughts, bright 
light, etc., and should be ordered to wear the blue eye protectors. 
Nor should they be permitted to strain their eyes with fine needle 
work or very small print, particularly by artificial light. Their 
diet must also be carefully regulated, and any over-indulgence in 
wine or alcohol strictly forbidden. Inattention to these different 
points frequently causes the recurrence of the inflammation. 

3.— FUNCTIONAL DISTURBANCES OF THE IRIS. 

(1.) Mydriasis. 

Although the dilatation of the pupil is generally considerable, 
it is not so extreme as that produced by a strong solution of atro- 
pine, where the iris is contracted to a very narrow, hardly per- 
ceptible rim. The dilatation of the pupil may be uniform and 
regular, so that the pupil retains its circular form, or it may be 
partial and irregular, the pupil thus acquiring a somewhat ovoid 
shape. The pupil besides being dilated, is more or less immoveable, 
acting but slightly, or not at all, upon the influence of light, the 
effort of accommodation, or the convergence of the visual lines. 
The sight is also somewhat affected, which is due in part to the 
bright glare which is experienced on account of the wideness of 
the pupil, and also in part to the circles of diffusion formed upon 
the retina. If the impairment of sight be simply due to the 
mydriasis, it will be remedied if the patient looks through a small 
circular opening in a card, or through the stenopaic apparatus, for 



182 



DISEASES OF THE IBIS. 



then the glare will be diminished, and the formation of circles of 
diffusion prevented. But very frequently paralysis of the ciliary 
muscle coexists with the dilatation of the pupil, and the impair- 
ment of vision is chiefly due to the loss of accommodation. The 
features which distinguish the symptoms due to loss of accommo- 
dation from those which are simply caused by mydriasis, are 
frequently overlooked by medical men, and thus much confusion 
is often produced in the narration of cases. Nor is it of unfrequent 
occurrence that the symptoms of amblyopia, produced by paralysis 
of accommodation, are referred to some serious intra-ocular or 
cerebral lesion. There is not, however, a necessary relation 
between the degree of dilatation of the pupil and the paralysis of 
the ciliary muscle, for the pupil may be widely dilated and the 
ciliary muscle but slightly, if at all, affected ; the converse is, 
however, of less frequent occurrence. 

When the pupil is widely dilated, it no longer presents its usual 
brilliantly black appearance, but assumes a somewhat grayish tint, 
which is due to the greater amount of light reflected from the 
lens and the fundus of the eye. 

Mydriasis is generally monocular, unless it is due to some cere- 
bral cause, or to a deep-seated intra-ocular lesion affecting both 
eyes. Monocular mydriasis often produces considerable disturb- 
ance of sight, on account of the difference in 'the brightness of 
the two retinal images, and the presence of circles of diffusion. 
For the purpose of accurately measuring the size of the pupil, Mr. 
Zachariah Laurence's " Pupillometer" [Fig. 57], will be found very 
useful. 

["The pupillometer consists essentially of two parts: 1, a pair 
of indices or ' sights ;' and 2, a graduated scale. The sights are 

formed by two vertical, knife' 
edged, brass bars (indices); the 
one (m) fixed; the second (/) 
movable by means of a screw (s), 
the head of which (h) is furnished 
with several small projecting 
spokes, by which the screw may 
be'turned with great delibacy by 
the tip of the finger. The hori- 
zontal plate (p), the scale to 
Avhich these indices are attached, 
is of white metal, and is gradu- 
ated into whole, half, and quarter 
lines. The scale is graduated on 
both sides, so that, by simply 
reversing the instrument, the 
pupil of each eye may be succes- 
sively measured. The applica- 
tion of the pupillometer is ob- 
vious, from the annexed figure. 
The edge of the fixed index (m) 
is held in a line with the inner 




FUNCTIONAL DISTURBANCES OF THE IRIS. 183 

edge of the pupil, and then the moveable one (/) is gradually 
screwed up till its edge corresponds exactly with the outer edge of 
the pupil. The interval between the two indices represents the 
diameter of the pupil." 1 ] 

Causes. — Before entering upon the different causes which may 
produce mydriasis, it will be well briefly to consider the action of 
certain substances upon the condition of the pupil, either in in- 
creasing or in diminishing its size. Certain substances, more 
especially belladonna, hyoscyamus, and stramonium, have the 
power of producing a marked dilatation of the pupil, and are 
hence termed mydriatics. We shall here, however, confine our 
attention to the action of atropine upon the pupil and the accom- 
modation. In numerous experiments made by Donders, 2 it was 
found that if a solution of four grains of sulphate of atropine to 
an ounce of water was applied to the eye, the pupil began to 
dilate within fifteen minutes, arriving at the maximum degree of 
dilatation in from twenty to thirty-five minutes, and finally com- 
plete immobility ensued. The younger the individual and the 
thinner the cornea, the more rapid was the action. The diminu- 
tion in the power of accommodation commences somewhat later 
than the dilatation of the pupil, but gradually returns, together 
with the mobility of the pupil, after some days. After the lapse 
of forty-two hours there is generally a slight diminution in the 
size of the pupil, accompanied by some accommodation, which 
increases with tolerable rapidity up to the fourth day, but does 
not become perfect till about the eleventh day. The weaker the 
solution of atropine, the longer will it take to act, and the less and 
more transitory will be its effect. By employing an extremely 
weak solution (gr. j to eight or ten ounces of water), we may 
dilate the pupil without affecting the accommodation. That the 
action of the atropine is due to its absorption through the cornea, 
is proved by the experiments of Von Graefe, 3 who withdrew some 
of the aqueous humor from the eye of a rabbit, the pupil of which 
was dilated by atropine, and applying it to the eye of another 
rabbit, it was found to produce dilatation of the pupil. 

The action of the atropine appears to be twofold ; it produces 
dilatation of the pupil, partly, by paralyzing the sphincter pupillfe, 
which is supplied by the third nerve, and partly by exciting the 
radiating fibres of the iris, which are supplied by the sympathetic. 
The truth of this hypothesis appears to me to be incontrovertibly 
proved by Ruete's 4 observation, that in dilatation of the pupil due 
to complete paralysis of the third nerve, the application of atropine 
produced still further dilatation. This is certainly opposed to the 
theory advanced by some observers, viz., that the paralysis of the 
sphincter pupillse permits the sympathetic nerve to exert an un- 

[' Laurence and Moon's " Handy -Book of Ophthalmic Surgery," p. 20.] 

2 Donders "Anomalies of Refraction and Accommodation," p. 585. 

3 "A. f. 0.," I. 1, 462, note. 

« Klin Beitrage z. Pathol, und Physiol, der Augen and Ohren. Braunschweig, 
1843. 



184 DISEASES OF THE IRIS. 

opposed action in dilating the pupil. Moreover, it is found that 
in mydriasis due to paralysis of the third nerve, the pupil is not 
dilated ad maximum, even although the affection may have lasted 
some time ; but on the application of atropine the widest dilatation 
at once ensues. 

Calabar bean produces excessive contraction of the pupil, together 
with a contraction of the ciliary muscle, and an artificial myopia. 
Its action will be more fully explained in the article upon the 
" Affections of the Accommodation." I think there can be no 
doubt that it chiefly produces its effect upon the pupil by exciting 
the nerves to the sphincter pupillse, although the myosis may also 
be in part due to the paralysis of the radiating fibres of the iris 
supplied by the sympathetic. But the spasmodic contraction of 
the ciliary muscle speaks strongly in favor of the excitation of the 
third nerve. 

Idiopathic mydriasis is not unfrequently due to rheumatic origin, 
the patient having been exposed to cold or wet, and it is in such 
cases probably caused by rheumatic inflammation of the nerve 
sheaths. It is generally accompanied by more or less complete 
paralysis, of some or all the muscles supplied by the third nerve. 
It may be also due to syphilis. I have met with a few instances 
in which a varying degree of mydriasis appeared in one eye, and 
in which all the ocular muscles were unaffected ; the ciliary muscle 
also being either not at all, or only very slightly, affected. In 
these cases, the affection could be traced to no other cause than 
syphilis, and the mydriasis had occurred some time after the 
secondary symptoms. The dilatation of the pupil yielded gradu- 
ally, but slowly, to the administration of iodide of potassium, and 
the occasional application of a blister behind the corresponding 
ear. Mr. De Me"ric, in an interesting paper read before the British 
Medical Association at Leeds (1869), reports several cases of syphi- 
litic mydriasis. In one case, all the ocular muscles were paralyzed, 
and the mydriasis was considerable; there had, however, been 
caries of the orbit. In two other cases, the mydriasis was accom- 
panied by ptosis, in another the latter was absent, but the dilata- 
tion of the pupil very obstinate. In two cases the secondary 
symptoms had quite vanished, in another the tertiaries were on the 
wane. 

Mydriasis may likewise be caused by direct injury to, or com- 
pression of the nerves supplying the constrictor pupillse, as, for 
instance, in consequence of severe blows upon the eye, or of an 
increase in the intra-ocular tension. In those cases in which it is 
caused by a blow, the mydriasis is not unfrequently partial, only a 
certain portion of the sphincter pupillge being affected. 

Mydriasis may be also due to irritation of the sympathetic, as 
may be seen in certain spinal diseases. The ephemeral dilatation 
of the pupil, which occasionally occurs for a short time at different 
periods of the day, is also probably due to this cause. Von Graefe 
has called attention to the interesting and important fact, that this 
ephemeral mydriasis is sometimes a premonitory symptom of in- 



FUNCTIONAL DISTURBANCES OF THE IRIS. 185 

sanity, more especially of ambitious monomania. The dilatation 
met with in helminthiasis may also be ascribed to irritation of the 
sympathetic. 

Dilatation of the pupil is also a common symptom in certain 
diseases of the brain, e. g., meningitis, hydrocephalus, and diseases 
of the cerebellum, also in many intra-ocular diseases, in which the 
sensitiveness of the retina is much diminished. In exceptional 
instances, the pupil may still act perfectly, even although the eye 
is absolutely blind. In such cases, the eonduetibility of the optic 
nerve, and the reflex action which it produces on the ciliary nerves 
are unimpaired, but the image is not perceived by the brain. 

Treatment. — In the rheumatic form of mydriasis a blister should 
be applied behind the ear, and iodide of potassium, or a preparation 
of guaiacum, should be administered internally. I have, however, 
often found a far more marked and rapid effect to reeult upon the 
paralysis of the accommodation from the application of the blister, 
than upon the mydriasis. If the dilatation of the pupil does not 
yield to these remedies, but shows a tendency to become chronic, 
tincture of opium should be dropped into the eye, electricity should 
be applied, and the use of Calabar bean may be tried. The latter 
remedy should not, however, be applied of too great a strength, or too 
frequently, otherwise it will produce too much fatigue of the sphinc- 
ter pupillse, instead of simply moderately stimulating it. Frequent 
and firm closure of the eyelids, convergence of the visual lines, and 
repeated exercise in reading, etc., are also of advantage in stimu- 
lating the contraction of the pupil. 

In very rare instances, the faculty exists of voluntarily dilating 
the pupil. Seitz 1 mentions a case of a young student, who was able 
voluntarily to produce a dilatation of about three millimetres by 
taking a deep inspiration, and then holding his breath, at the same 
time making a strong effort, during which the muscles of the neck 
and back became very tense. The experiment succeeded best when 
he regarded an object lying but a short distance from the eye. 

(2.) Myosis. 

Idiopathic myosis is of rare occurrence. The pupil is in such 
cases often extremely contracted, perhaps to the size of a pin's 
head, or even less, and acts but very slightly on the stimulus of 
light. Even strong solutions of atropine produce but a very 
moderate degree of dilatation. On account of the extreme minute- 
ness of the pupil, but little light is admitted into the eye ; the 
retinal images are consequently but slightly illuminated, and the 
vision on this account more or less impaired. The small size of 
the pupil also causes a considerable contraction of the peripheral 
part of the field of vision. 

Myosis may be caused by a spastic affection of the sphincter 
pupillse, or by a paralyis of the radiating fibres of the iris. The 

1 " Augenkeilkunde," p. 315. 



186 DISEASES OF THE IRIS. 

irritation of the branch of the third nerve, which supplies the 
sphincter pupillse, may be due to some central cause, or to reflex 
action from the fifth nerve. It may also be produced by too great 
and long-continued a use of the eyes at very minute objects, such 
as watch-making, engraving, etc. ; in consequence of which, the 
sphincter pupillae in time acquires a preponderating power over 
the dilatator. The myosis due to paralysis of the dilatatorpupillse 
is met with in those spinal lesions in which the sympathetic nerve 
is affected, so that its influence upon the radial fibres of the iris is 
impaired. Dr. Argyll Robertson reports 1 a very interesting case 
of spinal affection, in which there was marked myosis in both eyes, 
the pupils being about the size of a pin's point. Even a strong 
solution of atropine had but an imperfect and transient effect, but 
Calabar bean contracted the pupil still more, to sibout \ of a line. 
A tumor 3 or aneurismal swelling 3 pressing upon the cervical por ; 
tion of the sympathetic may also produce myosis. 

In the peculiar condition termed hippus there is a chronic spasm 
of the iris, producing rapid contractions and dilatations of the 
pupil, which follow each other in quick succession and are in- 
dependent of the influence of light. It. is generally allied with 
nystagmus. 

The treatment of myosis must of course vary with the cause} 
which is often situated at a distance from the eye. Periodic in- 
stillations of atropine should be tried, although they • generally 
have but a slight and only temporary effect upon the myosis. 



4.— TREMULOUS IRIS (IRIDODONESIS). 

The most frequent cause of this condition is absence of the lens, 
or its partial or complete dislocation. In such cases, the iris will 
be observed distinctly to oscillate and tremble when the eye is 
moved in different directions. In cases of partial dislocation of 
the lens, the tremulousness will be confined to that portion of the 
iris which has lost the support of the lens. 

This condition may also be observed in those cases of hydroph- 
thalmos in which the size of the anterior chamber is much in- 
creased, and the iris is stretched sideways, thus losing the support 
of the lens. 

It was formerly supposed that a fluid condition of the vitreous 
humor produces undulation of the iris. That this is, however, not 
the case is proved by the ophthalmoscope, for we often meet with 
cases in which a fluid condition of a considerable portion, or the 
whole, of the vitreous humor may be diagnosed from the wide ex- 
cursion made by the floating vitreous opacities, and yet the iris 
does not show the least tendency to tremulousness. 

' " Edinburgh Med. Journal," Feb. 1869. 

* Willebrand, "A. f. 0.," i. 1, 319. 

3 Gairdner, "Monthly Journal of Medicine," 1855 (vol. xi. p. 75). 



WOUNDS OP THE IEIS. 



187 



5.— WOUNDS OF THE IRIS, ETC. 

Punctured or incised wounds of the iris are not generally followed 
by such serious consequences as might have been supposed, as long 
as the lens has escaped injury. That the iris is not very impatient 
of such wounds is sufficiently proved by the operation of iridectomy, 
or the accidental incision of the iris in the performance of extraction 
of cataract, or again, the puncture of the iris which may occur 
during the needle operation for the solution of cataract, or the 
division of remains of opaque capsule. Such operations are, as a 
rule, not followed by iritis. Wounds which have torn and dragged 
the iris, are more dangerous than those which have simply pro- 
duced a clean cut. 

Blows upon the eye from a blunt foreign body, such as a piece 
of wood, a cork from a ginger-beer or soda-water bottle, etc., may 
cause a rupture of the continuity of the iris [Fig. 58], but more 



[Fig. 58. 




Fig. 59. 




After Lawson. 



After Lawson. 



frequently still, a rupture at its great circumference, tearing it 
away from its ciliary attachment, and thus producing a more or 
less extensive coredialysis. [Fig. 59.] This is the more likely to 
occur if the edge of the pupil is tied down by adhesions to the 
capsule. These secondary pupils may be readily recognized with 
the oblique illumination, and still more easily with the ophthalmo- 
scope, for the red reflex from the fundus oculi will appear likewise 
through this pupil. Such accidents, as well as the incised wounds 
of the iris, are generally accompanied by more or less effusion of 
blood into the anterior chamber. 

Mr. Lawson 1 narrates an extraordinary case of " laceration of the 
iris, without injury to any of the external coats of the eye, from 
the splash of a bullet, after it had hit the target, striking the eye," 
which was under the care of Mr. Critchett. The external coats 
of the eye were quite uninjured, and the outer part of the cornea 
only presented a slight unevenness of its epithelial surface, without, 
however, showing any opacity or any mark indicating the point 
which received the blow. " On looking, however, within the eye, 
two distinct pupils are at once seen, the one immediately above 



■Injuries of tlie Eye, Orbit, etc.," p. 123. 



188 



DISEASES OF THE IRIS. 




After Lawson.] 



the other ; the lower is separated from the upper one by a bridge 
of iris ; and the upper pupil is bounded by a border of iris, so that 

it is distinct from, and does not en- 
croach on the ciliary attachment 
of the iris. [Fig. 60.] The mar- 
gins of the new pupil when care- 
fully examined are found to be 
slightly lacerated and irregular." 

[Dr. Chisolm 1 has recorded a re- 
markable case of complete removal 
of the iris by the finger-nail of an 
antagonist. Whilst under excite- 
ment his patient suffered no pain, 
and was not aware, at the time, that 
his eye had been injured. The next day he discovered the change of 
color in his eye, and detected a shred of membrane protruding from 
a scratch on the front of the eyeball. After one or two days this 
fragment came away, leaving a white scar over the sight. ~No 
severe inflammation followed the injury, and so little inconvenience 
was experienced that he did not think it necessary to seek pro- 
fessional advice, nor did he lose a day's work.] 

Cases of rupture of the smaller circle of the iris, accompanied by 
dilatation of the pupil, have been narrated by Mr. "White Cooper. 
Wecker has, however, seen a case in which the sphincter pupillse 
was ruptured from a violent blow upon the eye, without any con- 
secutive dilatation of the pupil. 

A very peculiar and rare condition is that of retraction or depres- 
sion of a portion of the iris, which is sometimes produced by blows 
upon the eye. The portion of the iris which is depressed, is folded 
back upon itself, and the inner pupillary circle disappears at the 
point where this folding occurs; the peripheral portion of the iris 
is quite invisible, having sunk back out of sight, so that the eye at 
this point presents the appearance as if an iridectomy had been 
made quite up to the ciliary attachment. On examining the eye 
with the oblique illumination or with the ophthalmoscope, we can- 
not, however, detect a trace of the ciliary processes, as would be the 
case if the iris had been removed. 2 

In such cases the lens has generally been found partially dislo- 
cated or much diminished in size. 

The treatment of injuries to the iris must be directed to diminish- 
ing any inflammatory symptoms which may supervene. Atropine 
should be frequently dropped into the eye, leeches should, if neces- 
sary, be applied to the temple, and, for the first few hours after the 
accident, cold compresses will afford great relief and assist in check- 
ing a tendency to inflammation. If" there is any prolapse of the 
iris through the corneal wound, or if the lens has been injured, the 

[' " Amer. Journal of Med. Sci.," July, 1872, p. 125.] 

s For a description of cases of this interesting affection, vide " Mooren's Ophthal- 
miatrische Beobachtuugen," p. 131, and Wecker's "Traite des Maladies des 
Yeux," vol. i. p. 425. 



TUMORS OF THE IRIS. 189 

treatment laid down in the articles upon " Wounds of the Cornea" 
and " Traumatic Cataract" must be pursued. 

Small foreign bodies, such as splinters of steel or glass, portions 
of gun-cap, etc., may become lodged in the iris, or may injure it in 
their passage to the back of the eye. The presence of even a minute 
foreign body in the tissue of the iris is a source of constant irrita- 
tion, and consequently soon sets up more or less severe inflamma- 
tory complications, giving rise to corneo-iritis, or perhaps suppura- 
tive irido-choroiditis. It is, therefore, most advisable to extract a 
foreign body in the iris as soon as possible. The best mode of doing 
this is by an iridectomy, the segment of iris in which the foreign 
body is lodged being excised. 



6— TUMORS OF THE IRIS, ETC. 

Cysts of the iris are comparatively a rare affection, and are almost 
always the result of some injury to the iris. Thus they have been 
met with after the lodgment of foreign bodies in the iris, penetrat- 
ing or incised wounds of the latter, blows upon the eye, or even 
after operations for cataract, such as the operation of division or 
the common flap extraction. Sometimes it is difficult to discover 
the exact cause, or to ascertain with certainty that any accident 
has ever occurred to the eye. In such cases, a very careful exami- 
nation may, however, sometimes lead us to 
detect a slight opacity of the cornea, the re- 
mains of a former perforation. 

The cysts generally appear in the form 
of small transparent vesicles, situated on 
the surface of the iris, from which they may 
spring from a broadish base [Fig. 61] or a 
little pedicle. Their contents, instead of 
being limpid and transparent, may be 
opaque, causing the cyst to assume the ap- 
pearance of a little pearl. Yon G-raefe 1 re- 
cords a case in which the contents were sebaceous, soft, and pulpy, 
and in this cyst there were also found a number of short thick hairs. 
A similar case is described by Mr. White Cooper, 2 but in this the 
cyst was tough and hard, like cartilage, and was torn away bit by 
bit with the canula forceps. The little growth appeared to be made 
up of epithelial cells, closely packed together. 

The presence of the cyst may not be productive of any particular 
inconvenience or impairment of the sight, except inasmuch as the 
latter may be interfered with by the cyst protruding more or less 
into the area of the pupil. But in other cases, it sets up a consider- 
able degree of irritation, accompanied by ciliary injection, photopho- 
bia, lachrymation, etc., or it may even give rise to iritis. In a case 

> "A. f. O.," iii. 2, 412. 

2 "London Journal of Medicine," Sept. 1852. 




190 DISEASES OP THE IRIS. 

narrated by Mr. Hulke 1 sympathetic inflammation of the other eye 
was set up, which yielded rapidly after the excision of the cyst. 

In an interesting paper upon cysts of the iris, Mr. Hulke says : 
"An examination of all the cases which I have been able to collect 
shows: I. that cysts, in relation with the iris projecting into the 
anterior chamber, originate in two situations — 1, in the iris ; and 
2, in connection with the ciliary processes. The first lie between 
the uveal and the muscular stratum of the iris, and are distinguished 
by the presence of muscular fibres upon their anterior wall ; the 
second lie behind the iris, and bear the uveal as well as the muscu- 
lar strata on their front. II. It also shows that these cysts are of 
more than one kind ; that there are — 1, delicate membranous cysts, 
with an epithelial lining, and clear limpid contents ; 2, thick walled 
cysts, with opaque thicker contents (whether these are generally dis- 
tinct from 1 we are not yet in a position to determine, but it seems 
probable that they are so) ; 3, solid cystic collections of epithelium, 
wens or dermoid cysts ; 4, cysts formed by deliquescence in myxo- 
mata." 

Wecker 2 believes that serous cysts are never developed in the 
iris, but that they are the result of sacculation of the latter; and 
that the formation of the cyst does not take place by the distension 
of, a pre-existing space in the tissue of the iris, but that this space 
(a fold or sacculation of the iris) is caused either by injury or in- 
flammation, the serous contents being the aqueous humor. 

The tissue of the iris covering the anterior cyst-wall generally 
becomes so stretched and attenuated, that the limpid contents of 
the latter are perfectly distinguishable, and we can often see quite 
through it to the posterior wall. 

The best mode of treatment is the excision of the cyst, together 
with the segment of the iris to which it is attached. Puncturing 
or laceration generally proves unsuccessful, as the cyst very rapidly 
refills. But its excision, combined with iridectomy, is not always 
free from danger, as was shown in Von Graefe's case; 3 where the 
operation was followed by severe purulent cyclitis ; probably from 
a portion of the cyst having been left behind, and becoming the 
source of the inflammatory complications. 

Cysticerci of the iris will be treated of in the article upon " The 
changes in the contents of the Anterior Chamber." 

Ncevi of the iris are almost always congenital, and present the 
appearance of small black patches or elevations, which remain sta- 
tionary and cause no irritation. 

Teleangiectasis or nsevus of the iris is an extremely rare affection. 
Mooren 4 describes a very extraordinary case of this kind in which 
a dark tumor, resembling a blackberry in size and appearance, 
was situated on the external portion of the iris, extending some- 
what into the pupil, without, however, in the least impairing the 



K. L. O. H. Rep.," 6, 12. 

of Ophthalmolo c 

Ophthal. Beobachtungen," 125. 



..w. U. ~. ~~. ...w^., V, *«. 

Knapp and Moos' "Archiv. of Ophthalmology and Otology," I. 1, p. 
"A. f. O.," xii. 2, 228. i "Ophthal. Beobacl 



TUMORS OF THE IRIS. 191 

sight. The tumor, whose anterior surface touched the cornea, was 
traversed by several dilated bloodvessels, which could be seen to 
shine through from, the rusty brown back ground of the growth in 
the form of bright red, wavy lines, to be again lost in it after a 
short course. The ophthalmoscope did not reveal the slightest 
change in the fundus., The most extraordinary feature of the case 
was that when the patient, after having shaken his head, stooped 
rapidly forward, the whole anterior chamber became filled with 
light-colored blood. The sight (which was a few moments before 
perfectly good) was at once reduced to a mere perception of the 
difference between light and dark. When the patient had held 
his head still for a few seconds, the hemorrhage began at once to 
disappear, the upper portion of the iris became apparent, then the 
upper part of the pupil, and so on, until, in the course of about a 
minute and a half, every trace of the hemorrhage had vanished, 
and the sight had resumed its normal standard. Each repetition 
of the experiment produced the same astonishing phenomena, nor 
was Mooren able, in spite of the most careful and minute exami- 
nation, to detect the source of the hemorrhage. The excision of 
the tumor was proposed, but refused by the patient. Four years 
later he again presented himself, the appearance of the eye having 
in the mean time undergone a considerable change. The hemor- 
rhage had entirely disappeared since about a year, the tumor had 
become reduced to about one-third of its original size, its color had 
assumed a dirty gray tint, and, instead of the dilated vessels, nu- 
merous isolated black deposits of pigment were now apparent. The 
intra-ocular tension had increased, and the sight diminished to the 
spelling with difficulty letters of 16, and the Held of vision was 
contracted. There was slight excavation of the optic nerve. The 
patient again refused an iridectomy. Some months later, the 
glaucomatous changes having led to a complete loss of sight, the 
patient submitted to an iridectomy, on account of the very severe 
ciliary neuralgia which had supervened. The little shrunken 
tumor was sent to Dr. Schweigger for examination, who, as Mooren 
says, doubtlessly did not receive it, as its receipt was never acknowl- 
edged by him. The other eye was subsequently affected with sym- 
pathetic irido-choroiditis, which yielded to an iridectomy. 

Cancer of the iris is almost always due to an extension of the 
disease from the deeper tunics of the eye ; it is extremely rare as a 
primary affection of the iris, and is then generally melanotic in 
character. It appears in the form of a small, dark, yellowish-brown 
elevation or tubercle at one point of the iris, perhaps somewhat 
resembling a little syphilitic button or condyloma. The tumor 
may remain stationary for a length of time, or rapidly increase 
more and more in size, and protrude into the anterior chamber in 
the form of a dark brown or blackish mass, which either perforates 
the cornea or the anterior portion of the sclerotic, which becomes 
staphylomatous at this point, and gradually yielding, the tumor 
sprouts forth. As soon as the true nature of the disease is recog- 
nized, no time should be lost in excising the eyeball. This is much 



192 



DISEASES OF THE IEIS. 



wiser than removing only the anterior half of the eye, as a similar 
disease may exist in the deeper tunics. Hirschberg 1 records a case 
of primary melano-sarcoma of the iris, in which the latter was 
alone implicated, the tumor having been developed from the an- 
terior portion of the iris, and the elements of the ciliary body being 
perfectly unchanged. He moreover points out with regard to the 
diagnosis between the simple and sarcomatous (malignant) tumors 
of the iris, that they first occur in children between the ages of 
1 — 12, and are of a light yellowish-white color, and often very 
vascular, their surface being uneven and somewhat ragged ; whereas 
the sarcomata have a darker color and a smooth surface. 



7.— CONGENITAL ANOMALIES OF THE IRIS. 

Congenital Irideremia, or absence of the iris, is occasionally here- 
ditary. I have seen one instance in which the iris was completely 
wanting in both eyes of the father, this condition being accom- 
panied by a partial luxation and opacity of the crystalline leuses ; 
and in the son (an infant a few months old) there was total iride- 
remia in both eyes, but the latter appeared otherwise quite normal. 
Sometimes the iris is not completely wanting ; a small rudimentary 
portion, of varying size, being apparent at the periphery. Absence 
of the iris is often accompanied by opacity or displacement of the 
lens, nystagmus, and imperfect development of the cornea, which 
perhaps does not acquire its normal size. The power of accommo- 
dation may also be impaired, but this is not due, as was formerly 
supposed, to the absence of the iris, but may be caused by an arrest 
in the development of the ciliary body. In those cases in which 
irideremia is not accompanied by any other affection, the sight may 
be very good, more especially if the glare of the light and the 
circles of diffusion upon the retina are diminished by the use of 
stenopaic spectacles. 

Coloboma, or partial deficiency of the iris (cleft iris), is almost 
always accompanied by a cleft in the ciliary body and choroid. It 
is due to an arrest in the development of the iris, and may vary 

(very much in size and shape. The 
[ Fi S- 63 - coloboma is generally situated at the 

^gg|§§ljj§|js|j [ lower, or lower and inner, portion of the 

iris, and is irregularly triangular or py- 
riform in shape, the base of the triangle 
being turned towards the pupil, the apex 
towards the periphery. [Fig. 62.] Colo- 
boma of the iris generally affects both 
eyes ; sometimes it is confined to one, 
generally the left, and is often accompa- 
nied by other congenital anomalies of 
the eye, such as cleft of the eyelids, con- 




"A. f. 0.,"14, 8,285. 



CONGENITAL ANOMALIES OF THE IRIS. 193 

genital cataract, microphthalmos, nystagmus, cleft palate, etc. The 
fissure in the iris does not necessarily extend quite up to the peri- 
phery, but at the latter point a margin of iris may exist, uniting 
the two edges of the cleft. Moreover, the area of the coloboma 
may be closed by a rudimentary, darkly pigmented membrane, 
which might cause the deficiency of the iris" at this point to be 
altogether overlooked by a superficial observer (Seitz). If the 
fibrous layer of the iris is deficient to a greater extent than the 
uveaUayer, the edge of the cleft is fringed with a distinct black 
margin. In simple coloboma iridis, the acuity of vision is gene- 
rally pot at all affected ; it may be very different, however, if the 
affection is associated with a considerable cleft in the ciliary body 
and choroid. 

Amongst the other congenital anomalies of the iris, we must call 
attention to the eccentric position of the pupil {corectopia), and to 
the cases in which there exists more than one pupil (polycoria). The 
eccentric displacement of the pupil may sometimes be so slight that 
it is hardly observable, but in other cases it is well marked, there 
being only perhaps a small rim of iris at the side towards which 
the pupil is displaced. Sometimes both eyes are affected, and then 
the displacement of the pupil may be symmetrical. I had, some 
time ago, under my care at the Royal London Ophthalmic Hospital, 
two very interesting cases of corectopia, occurring in two sisters. 
In each eye the pupil was displaced, and the lens dislocated, both 
these conditions being congenital. The eyes of the parents were 
quite normal. 

In cases of polycoria, a second pupil may exist at some little dis- 
tance from the original one, being separated from it by a more or 
less considerable band of iris, the second pupil being, in fact, a 
partial coloboma (annular) of the iris. In other cases, several small 
pupils exist near the normal one, being separated from it and each 
other by narrow trabecular of iris, and this condition is evidently 
closely allied to that of persistent pupillary membrane. The exist- 
ence of two or more pupils does not generally produce any impair- 
ment of sight, or give rise to monocular diplopia or polyopia. 

Persistence of the pupillary membrane is a rare affection, and is 
characterized by the presence of one or more delicate fibrillar bands, 
springing from the larger circle of the iris, and passing over the 
smaller circle into the pupil, which they may either cross to be 
inserted at the other side into the larger circle of the iris, or they 
may pass over into a thin, pigmented, circumscribed membrane, 
situated in the area of the pupil, and perhaps attached to the 
capsule of the lens. These large trabecular are often connected to 
each other by numerous crossbars of delicate fibrillae. 1 "Weber 2 has 
described a very interesting case, in which the fibres formed a 
series of arcades. The fibrillar were very thin and delicate, and 

1 For several interesting cases of this affection, as well as for a brief resume of 
the cases hitherto described in ophthalmic literature, vide two articles of Conn's in 
" Kl. Monatsbl., 1867, pp. 62 and 119. 

2 "A. f. O.," viii. 1, 337. 

13 



194 



DISEASES OF THE IRIS. 



were about 18 or 20 in number, and united by numerous thin 
fibrillar cross-bars. They sprung from the larger circle of the iris, 
and passed straight over the lesser circle to the centre of the pupil, 
which was occupied by a circumscribed, pigmented, membranous 
patch, firmly attached to the capsule of the lens. Into this mem- 
brane the fibrillse were inserted. The remaining portions of the 
capsule, as well as the edge of the pupil, were quite free from any 
deposits or adhesions, and the pupil acted perfectly under the in- 
fluence of light. It appears probable that these remains of the 
pupillary membrane are more frequent in young children, giving 
way and disappearing as the person gets older. Their true nature 
is, moreover, sometimes overlooked, they being mistaken for simple 
adhesions between the pupil and the capsule of the lens. 



8— OPERATIONS FOR ARTIFICIAL PUPIL. 

It is unnecessary to enter into a description of the various modes 
of making an artificial pupil which have been in vogue at different 
times, as they have now been all abandoned in favor of the follow- 
ing operations, of which that of iridectomy enjoys by far the widest 
and most varied application, and hence demands at our hands the 
most full and exact description. 



Fig. 63. 



(1.) IRIDECTOMY. 

The following instruments are required for the operation: — 
1. A silver wire speculum for keeping open the eyelids. Weiss's 
stop-speculum (Fig. 63) will be found the best, as, by means of an 
easily adjustable screw, it permits the eye- 
lids to be kept fixedly apart at any desired 
distance, so that they cannot press the 
branches together, and thus narrow the 
aperture. This form of speculum is seen in 
Fig. 63. If the patient 'should strain very- 
much, and the speculum presses upon the 
eyeball, an assistant should lift it forward 
a little, so as to remove it from the globe. 

2. A pair of fixing forceps for steady- 
ing the eyeball. They must catch accurate- 
ly, and the tooth should not be too sharp 
and pointed, otherwise it will easily tear 
through the conjunctiva. If the latter is 
thin and rotten (as is often the case in 
elderly persons) Waldau's fixation forceps 
are to be preferred, which, instead of being 
toothed, are finely serrated, so that they 
obtain a firm hold of the conjunctiva 
without tearing through it. 




IRIDECTOMY. 



19t 



3. A broad lance-shaped knife. It should be about the same 
width as that represented in Fig. 64. If it is much broader, the in- 
ternal wound will be considerably smaller than the external, and 
in order to enlarge it to the same size as the latter, the edge of the 
knife must be much tilted in withdrawing the instrument from the 
anterior chamber. But this proceeding is often somewhat difficult, 
and may prove dangerous in the hands of an inexperienced operator. 



Fis;. 64. 



Fig. 65. 




The shape of the knife must vary with the direction in which the 
iridectomy is to be made. If it is made outwards (to the temporal 
side) the straight knife is to be used. But if the iridectomy is 
made inwards or upwards, the blade must be bent at a more or less 
acute angle (Fig. 65), according to the prominence of the nose or of 
the upper edge of the orbit. If the anterior chamber is extremely 
shallow, so that the iris is nearly in contact with the cornea, and es- 
pecially if the pupil is at the same time dilated, it will be better to 
make the incision with Von (Iraefe's narrow cataract knife, than 
with the lance-shaped one. For with the former we can skirt the 
edge of the anterior chamber, and make a large incision without 
any risk of wounding the lens. 

4. The iris forceps should catch most accurately, and when closed, 
should be perfectly smooth at the extremity ;, for if they are rough 
and irregular, they will scratch and tear the iris and the lips of the 
incision, and thus perhaps set up some irritation. They may be 
straight (Fig. 66) when the iridectomy is made outwards, although 
I, even here, prefer to have them slightly bent. For the upward or 
inward operation they must be bent at a still more acute angle 
(Fig. 67). 

i 5. The iris scissors (Fig. 68) should be bent at an angle, and, 
though sharp, should not be too finely pointed. Care should be 
taken that the blades close tightly, and do not over-ride each other, 
which may easily occur in such slight scissors, if the joint is not suf- 
ficiently strong and firm. Instead of these, a pair of scissors curved 
on the flat [Fig. 69] may also be used. 



196 " DISEASES OP THE IBIS. 

Pig. G6. Fig. 67. Fig. 68. [Fig. 69.] 





The operation is to be performed in the following manner: The 
patient is to be placed in the recumbent position, either in bed or 
on a couch, the head being slightly elevated. Unless there be very 
exceptional reasons to the contrary, chloroform should always be 
administered. I prefer to use it in all cases of iridectomy, especially 
if the eye is acutely inflamed, for the operation is then often very 
painful ; and, however courageous and determined the patient may 
be, he may find it impossible to control some sudden, involuntary 
movement of the eye or head, which may endanger the result of 
the operation, or even imperil the sai'ety of the eye. But if chlo- 
roform is employed, it should be given so as to anaesthetize the 
patient completely, and render him quite passive, otherwise he may 
prove far more unruly than if none had been administered : and 
the operation is of so delicate a nature that absolute quietude of 
the eye is necessary. If sickness should supervene, the further 
steps of the operation must be delayed until this has passed away. 



IRIDECTOMY. 



197 




Let us now suppose that an outward iridectomy is to be per- 
formed upon the right eye for the cure of glaucoma. If the 
operator is ambidexter, he may seat himself upon the couch or bed 
in front of the patient, and make the incision with his left hand. 
If not, he should place himself behind the patient. The eyelids 
having been opened to the desired extent by the stop-speculum, the 
operator should seize with a pair of fixing forceps the conjunctiva 
near the inner side of the cornea, exactly opposite to the place 
where the incision is to be made. The straight iridecto my knife 
is then to be thrust into the sclerotic, 
about half a line from the sclero-cor- 
neal conjunctiva (Fig. 70), and, the 
handle of the instrument being laid 
well back towards the temple, the 
point is to be passed into the anterior 
chamber at its very rim, and carried 
on slowly and steadily towards the op- 
posite side until the incision is of the 
desired extent. The knife is then to 
be slowly and gently withdrawn, the aqueous humor being allowed 
to flow off as slowly as possible, so that the relief of the intra-ocular 
pressure may not be sudden, otherwise this will cause a rapid over- 
filling of the intra-ocular bloodvessels, and perhaps a rupture of the 
capillaries of the retina and choroid, producing sometimes very 
extensive hemorrhage. When the knife has neen nearly withdrawn 
from the anterior chamber, the handle is to be somewhat depressed, 
so that the upper edge of the blade is slightly elevated, and the 
upper angle of the internal incision should then be enlarged to a 
size corresponding to the external incision. The same proceeding 
maybe repeated downwards, or the incision maybe enlarged to the 
required extent with a pair of blunt-pointed scissors curved on the 
flat, the one point being introduced just within the anterior 
chamber, and the incision then enlarged upwards and downwards. 

On the completion of the section, the forceps are to be handed 
over to an assistant, who should, if necessary, fix the eye, being, 
careful at the same time not to press 
or drag upon the eyeball, but simply 
to rotate it gently in its bed. If the 
iris does not protrude through the lips 
of the wound, the operator should pass 
the iris forceps (closed) into the ante- 
chamber, and then, opening them some- 
what widely, he should seize a fold of 
the iris, and draw it gently through 
the incision to the requisite extent, 
and cut it off with the scissors quite 
close to the lips of the wound (Fig. 71.) 
The excision of the iris may be done either by the operator himself, 
or by an assistant. In the former case, the iris forceps should be 
held in the left hand, and the scissors in the right, as it requires 




198 



DISEASES OF THE IRIS. 



some practice to use the latter well with the left hand. If a portion 
of the iris protrudes into the incision, there will be no occasion to 
introduce the forceps into the anterior chamber, but the prolapsed 
portion is to he seized, and, if necessary, drawn forth somewhat 
further and divided. 

The portion of iris may be excised with one cut, or else this may 
be done according to either of the following modifications intro- 
duced by Mr. Bowman. 

The protruding portion of iris may be drawn to the right-hand 
angle of the incision, and partly divided close up to the angle, the 
other portion being then gently torn from its ciliary insertion 
(slight snips of the scissors aiding in the division), and drawn to 
the opposite angle, to be there completely cut oft'. This mode of 
operating is illustrated in Fig. 72, a, the prolapse drawn down to 
the lower (right-hand) angle, a', of the incision, where the inferior 
portion is to be divided, and the other drawn up in the direction 
of b, to the upper angle of the incision. 





Or again, the prolapse (Fig. 73, a), may be divided into two 
portions at b. The lower portion is to be drawn in the direction 
of c, to the lower angle of the incision, and snipped off. The upper 
portion is then to be drawn in the direction of d, and also divided. 
Thereis, however, this disadvantage in this mode of operating, 
that, if there is much hemorrhage, the upper portion of iris is 
somewhat hidden, or it may slip back into the anterior chamber, 
and have to be searched for. 

But either method, if well accomplished, will yield an excellent 
artificial pupil. The iris will be torn away 
quite up to its ciliary attachment, and the 
pupil will consequently reach quite up to 
the periphery (Fig. 74). 

If there is any hemorrhage into the an- 
terior chamber, the blood should be per- 
mitted to escape before coagulation. A 
small curette is to be inserted between the 
lips of the wound, slight pressure being at 
the same time made upon the eyeball with 
the fixing forceps, so as to facilitate the escape of the blood. But 
if the latter does not escape readily, it should not be forced out, 
but be permitted to remain, as it will soon be absorbed, especially 
it a compress bandage is applied. 




IRIDECTOMY. 199 

I have described the mode of performing iridectomy in the out- 
ward direction, as this is the easiest, and it may therefore be wise 
for a perfectly unskilled operator to make it at first in this di- 
rection, until he has gained a certain degree of practice and dex- 
terity, and then to pass over to the upward or inward incision. 
The operation in* either of the latter directions is certainly more 
difficult than the temporal, on account of the prominence of the 
nose or upper edge of the orbit, and the consequent necessity _ of 
employing a knife bent at a more or less acute angle, which an 
unskilled operator may find somewhat difficult to keep quite fiat. 

The size of the iridectomy and the direction in which it is to be 
made, should vary with the purpose for which the operation is 
performed. Thus, if it be done solely for the purpose of arresting 
inflammation, or of diminishing intra-ocular tension, it should, if 
possible, always be made directly upwards, for then the upper lid 
will cover the greater portion of the artificial pupil, and thus not 
only hide the slight deformity, but also cut off much of the irregu- 
larly refracted light. In these cases, more especially in glaucoma, 
the incision should be made somewhat in the sclerotic, so that the 
iris may be removed quite up to the ciliary insertion, and should 
be of a sufficient size to permit of the excision of about one-fifth of 
the iris. "We find that if both these requirements are not fulfilled, 
the beneficial effect of the iridectomy in checking the inflammation 
and the increase in the tension is either greatly diminished or not 
permanent. 

But when iridectomy is performed simply for the purpose of 
making an artificial pupil through which to admit the light, as in 
opacity of the cornea, lamellar cataract, etc., it should be made of 
a much smaller size, and, if possible, inwards, as the visual line 
cuts the cornea slightly towards the inner side of the centre. But 
with regard to the position, we must be guided by the condition 
of the cornea, endeavoring to make the artificial pupil opposite to 
that portion of the cornea which is most transparent, and most 
true in its curvature. The incision should in these eases be slightly 
iu the cornea, so that a narrow belt of iris may be left standing, 
and the irregular refraction produced by the peri- 
phery of the cornea and of the lens, and consequent [Fig. 75.] 
confusion of sight, be diminished. For the same rea- 
son, the iridectomy should not be large, otherwise 
its base will expose a considerable portion of the edge 
of the lens. Hence the incision should be made with 
a narrow iridectomy knife, or even with a broad nee- 
dle. [Fig. 75.] If a very small incision is made, the 
iris may be drawn out with a blunt silver or pla- 
tinum iris hook, instead of the forceps, just as in the 
operation of iridodesis. This mode of operating is also 
indicated in those cases in which there are extensive 
adhesions between the edge of the pupil and the an- 
terior capsule. In such cases, the incision should, if 
possible, be made at a spot corresponding to a point at 



200 



DISEASES OF THE IRIS. 



which the edge of the pupil is unadberent, so that the hook may seize 
this portion of the iris. If the whole edge of the pupil is adherent, 
and the iris is thin and rotten, it is often impossible to obtain a good 
sized pupil, for the iris breaks down, and tears between the forceps, 
and only small portions can be removed piece-meal. Or again, the 
adhesions of the pupil to the capsule may be so firm, that they 
resist the traction of the forceps, and this portion of the iris re- 
mains standing. In fact we have performed the operation, which 
Desmarres has recommended in such cases, and has termed "iridor- 
hexis." A portion of the iris is excised, leaving the adherent 
pupillary edge standing. In order to overcome this difficulty in 
seizing the iris, Liebreich 1 has devised a pair of iridectomy forceps, 
in which the teeth are so situated that the surface in which they 
grasp is turned at a right angle ; in this way they can firmly seize 
the iris, just as a pair of fixing forceps. 



(2.) IRIDODESIS. 

This valuable and ingenious operation was devised by Mr. 
Critchett, 2 and is very useful in all cases in which we desire to 
obtain an artificial pupil for optical purposes only, as, for instance, 
in cases of opacity or conicity of the cornea, or of lamellar cata- 
ract, etc. 

The operation is to be performed in the following manner: The 
patient having been placed under the influence of chloroform, and 
the eyelids kept apart with the stop-speculum, the operator fixes 
the eyeball with- a pair of forceps, and makes an incision with a 
broad needle in the sclero-corneal junction, slightly encroaching 
upon the cornea. If the incision is made inwards (which is the 
best direction) and the nose is prominent, Mr. Critchett employs a 
broad needle bent at an angle on the flat. With regard to the 
size of the incision, it is of importance to remember, that whilst, 
on the one hand, it should be sufficiently large to admit of the 
easy introduction of the hook or forceps, it must not, on the other, 
be too wide, otherwise the strangulated portion of the iris, with 
the ligature, may be drawn into the anterior chamber when the 

aqueous humor reaccumulates. 
The incision having been com- 
pleted, and the broad needle 
removed, a small loop [A, Fig. 
76] of very fine black silk is 
to be placed directly over the 
wound. A blunt platinum or 
silver hook (bent at the requi- 
site angle) is then to be, intro- 
duced through the loop into 
the anterior chamber to the 




Knapp and Moos' Arcliiv., I. 1, 22. 



2 "R. L. O. H. Rep.," i. 220. 



IRIDODESIS. 



201 



proximate edge of the pupil, which is to be caught up by it, 
and then the portion of iris thus secured is to be'carefully and 
gently drawn forth into the loop. If it is desired to stretch the 
opposite portion of the iris, so as to bring it opposite an opacity in 
the cornea or lens, and thus to displace the pupil considerably to 
the side of the incision, the operator must be extremely careful 
that, whilst drawing forth the iris, he does not cause a separation 
of the opposite border from its ciliary attachment (coredialysis), 
which may be easily done if the iris be put too much upon the 
stretch, or drawn forth somewhat roughly. As soon as a sufficient 
portion of iris lies within the loop, an assistant, with a pair of 
broad cilia forceps [Fig. 77] in each hand, seizes the two free ends 



[Fig. 77.] 









JiiSHi 



[Fig. 78.] 



of the loop and ties this tightly, so as to include the prolapsed iris 
firmly within it. In tightening the ligature, he should not draw 
the ends of the loop away from the eye, but should follow the cur- 
vature of the sclerotic. The ends of the ligature are then to be 
cut oft', the one being left somewhat longer than the 
other, in order that it may be readily seized with 
the forceps, if the loop should show a tendency to 
be drawn into the anterior chamber. The little 
strangulated portion of iris quickly shrinks, and the 
loop may be removed orl the second or third daj'. 
But, instead of the hook, the canula forceps [Fig. 
78] may be employed, the iris being seized by them, 
about midway between the edge of the pupil and its 
ciliary attachment. The hook is, however, to be 
preferred. 

I have above described the operation which is to 
be performed when the artificial pupil is to extend 
to the periphery. But if we desire 
simply to displace and enlarge the 
original pupil from its central posi- 
tion towards one side, preserving at 
the same time the constrictor pu- 
pillse intact, the peripheral portion 
of the iris must be seized with the 
canula forceps, and drawn forth 

through the loop until the pupil occupies the desired position 
[Fig. 79], when the ligature is to be tightened. 

It may occasionally occur that, although the sight is considerably 
improved by the iridodesis, the patient greatly feels the want of 
more light, aud a stronger illumination of the retinal image. In 
such cases Mr. Oritchett has succeeded admirably, by making a 





202 



DISEASES OF THE IRIS. 



second iridodesis in the same eye, in such a manner as to enlarge 
the pupil and alter its shape, giving it a somewhat crescentic form, 
with the two corners of, the crescent cut oft'. 

The operation of iridodesis is, as a rule, quite free from danger, 
and productive of but very little irritation. In very rare instances 
it may however give rise to iritis, or even suppurative irido-cyclitis. 
Such cases have been recorded by Alfred Graefe, 1 Steffan, 2 etc., but 
although I have a large experience of the operation, both in the 
hands of others and in my own, I have never met with a single 
case in which it caused inflammatory complications. In order to 
avoid the risk of irritation, and also to simplify the operation, 
Wecker has suggested that the prolapse of the iris, instead of being 
tied, should be allowed to heal in the wound. He makes the 
incision rather further in the sclerotic, so as to obtain a long track ; 
he then seizes the iris with a very fine pair of iridectomy forceps, 
and draws it out into the incision. To maintain it in this position, 
and to accelerate the healing of the wound, a firm compress band- 
age is applied. The prolapse becomes firmly adherent in the track 
of the wound, and the little protruding portion soon drops off. 
This operation is termed " iridenkleisis." 



[Fig. 80. 



(3.) ARTIFICIAL PUPIL MADE BY INCISION OP THE IRIS. 

We sometimes find after a perforating wound or ulcer of the 
cornea, or the common flap operation for cataract with extensive 
prolapse, that the iris presents a plane surface 
tightly stretched from the cicatrix to the 
periphery of the cornea, and that there is no 
trace of a pupil. If the lens is absent, a very- 
fair artificial pupil may often be obtained 
in these cases by simply splitting the fibres 
of the iris across with a broad needle. The 
edges of the incision will generally retract, 
and a very good sized pupil be left [Fig. 80.] ; 
if this is not the case, a Tyrrel's hook [Fig. 
81]_ may be passed through the., corneal 
incision, and one edge of the incised portion 
of iris be caught, drawn forth, and excised. 




(4.) CORELYSIS. 

The detachment of adhesions between the edge of the pupil and 
the anterior capsule of the lens by operative interference, was first 
extensively practised by Mr. Streatfeild 3 and subsequently also by 
Weber. 4 The patient having been chloroformed, and the lids fixed 
with the stop-speculum, an incision is to be made in the cornea with 



' "A. f. O.," ix. 3, 199. 

» " R. L. 0. H. Rep.," i. 6, and 2, 309. 



2 Ibid., x. 1, 123. 

« "A. f. O.," 7, 1, and 8, 1,354. 



IRIDODIALYSIS. 203 

a broad needle, of sufficient size readily to admit the spatula hook 
into the anterior chamber. Prior to the operation, a strong solu- 
tion of atropine should be applied to the eye, so that any unadbe- 
rent portions of the pupil may become dilated. The exact position 
and size of the different posterior synechise should then be carefully 
ascertained with the oblique illumination, for upon their position 
and number must depend the situation of the incision, and with- 
regard to the latter it should be remembered that no adhesion, 
directly behind the incision through which the spatula hook has 
to be introduced, can be torn through. It is best, therefore, to 
make the incision at a point situated sidewaj'S to the principal 
adhesions ; thus if there are two adhesions opposite to each other, 
the incision should be made between them, so that by a simple half 
rotation of the spatula each may be easily torn through. If there 
are several adhesions and one broad unattached portion of the pupil, 
the incision should be made opposite the latter. Mr. Streatfeild re- 
commends that the broad needle should be rapidly withdrawn from 
the anterior chamber, so as to allow as little of the aqueous humor 
to escape as possible. "Whereas "Weber prefers to withdraw the 
instrument very slowly, so as to permit the gradual escape of the 
aqueous humor, in order that the crystalline lens may 
come in contact with the cornea and thus be steadied; Fig. 82. 
the spatula will glide over the former, and there is less 
chance of injuring the capsule. 

The incision having been finished, a small spatula hook 
[Fig. 82] is introduced into the anterior chamber, and, 
with a somewhat lateral " wriggling" movement, the 
instrument is passed slightly beneath the iris, at a point 
free of adhesions, and is then passed behind the nearest 
adhesion, and drawn gently and slowly towards the |||| 

operator; so that it breaks down the band before it, IIS 
care being taken to keep it quite parallel to the iris, lest ™ 
the capsule of the lens should be injured. The adhesion 
may yield at once before the pressure of the spatula , but if it resists, 
it may be caught in the hook and thus torn through. 

Dr. Passavant 1 does not use the hook in performing corelysis, 
but after having made the opening in the cornea with the broad 
needle, seizes the iris with a pair of iridectomy forceps, and, gently 
drawing it somewhat towards the incision, thus detaches the adhe- 
sion. "Where several posterior sjmechise exist, he repeats the ope- 
ration after a day or two. He has thus operated with success on 
more than fifty cases. 

(5.) IRIDODIALYSIS. 

If nearly the whole cornea is opaque, and there is only a narrow 
transparent rim left, it may be advisable to adopt this mode of 

' "A. f. O.," 15, 1, 359. 



204 DISEASES OF THE IBIS. 

forming an artificial pupil, for if the incision is made, as in iridec- 
tomy, in the selero-corneal junction, it is sometimes followed by 
some opacity of the cornea close to the incision, and this would 
prove very disadvantageous where the rim of clear cornea is but 
very narrow. An incision is made in the cornea with a broad 
neeflle, at a sufficient distance from the point where the iris is to 
•be removed from its ciliary attachment, for the forceps or hook to 
be easily managed. A fine pair of iridectomy (or canula) forceps 
is passed into the anterior chamber, a fold of iris seized, gently 
torn from its insertion, and a portion drawn forth through the 
incision and snipped oft". Thus a marginal pupil can be made 
opposite the transparent edge of the cornea. Should the vicinity 
of the incision become a little clouded, this will be at some distance 
from the new pupil. 

I must now briefly enumerate the different diseases in which an 
iridectomy is indicated. These may be divided into two groups, 
viz. : those affections in which the operation is performed for the 
purpose of diminishing inflammatory symptoms and an increase in 
the eye-tension, and those in which the object is simply to make an 
artificial pupil. 

In the first group it is indicated — 1. In ulcers of the cornea which 
threaten extensive perforation, or cases of suppurative corneitis. 
The iridectomy diminishes the intra-ocular tension, and thus affords 
a favorable opportunity for the process of reparation, and also im- 
proves the nutrition of the parts. 2. If the cornea, after perfora- 
tion, shows a tendency to become prominent and staphylomatous 
at this point, and more especially if there is any increase in the 
intra-ocular tension. 3. In obstinatefistul a of the cornea, and in 
prolapse of the iris. 4. In recurrent or chronic iritis and irido-cho- 
roiditis, particularly if the communication between the anterior 
and posterior chambers is interrupted by circular synechia. Also 
in cases in which a foreign body has become lodged in the iris, or 
a tumor or cyst exists in the latter. 5. In traumatic cataract ac- 
companied by much swelling of the lens substance, great irritation 
of the eye, and augmented tension. Also in various operations for 
cataract, the object being partly to prevent bruising of the iris 
during the extraction of the lens, and partly to diminish the tendency 
to subsequent inflammatory complications. 6. In the extensive 
group of glaucomatous diseases, in which there is increase of the 
intra-ocular tension, leading finally to excavation of the optic nerve 
and blindness. The importance of an early operation in such cases 
cannot be over-estimated. 

In the second class of cases, in which the object of the iridectomy 
is simply to afford an artificial pupil, it is indicated in the follow- 
ing affections: 1. In opacities of the cornea, also in conical cornea. 
In the latter case, the object of the operation is, however, strictly 
speaking, twofold, viz. : to diminish the intra-ocular tension, and 
also to make a pupil opposite a portion of the cornea whose curva- 



CHANGES IN FORM, ETC., OF ANTERIOR CHAMBER. 205 

ture is but slightly, if at all, altered. 2. In occlusion of the pupil 
after iritis. 3. In lamellar cataract, and in dislocation of the lens. 



9 — CHANGES IN THE FORM AND CONTENTS OF THE 
ANTERIOR CHAMBER. 

The size of the anterior chamber may undergo considerable alte- 
ration. Thus, if the intra-ocular tension be much augmented, or 
the iris is bulged forward by a collection of fluid, or by exudation- 
masses between the posterior surface of the iris and the capsule of 
the lens, the anterior chamber may be extremely shallow, the iris 
being perhaps almost in contact with the posterior surface of the 
cornea. Whereas, when the anterior portion of the eyeball is dis- 
tended and enlarged (hydrophthalmos), or when the crystalline lens 
is absent or displaced, the anterior chamber increases in depth. 
The size of the latter also varies according to the age, and the state 
of refraction. It diminishes with advancing years, and is deeper in 
myopic and more shallow in hypermetropic persons. 

Effusions of lymph and pus may take place into the anterior 
chamber, and sink down to the bottom in the form of hypopyon, 
which may attain a considerable size, and even fill the whole of the 
anterior chamber. The lymph or pus may be effused either from 
the cornea, the iris, or the ciliary body, as has been described at 
length in the articles upon the diseases of these parts. 

Blood may also be effused into the anterior chamber, this condi- 
tion being termed " hypsemia." The hemorrhage may be either 
spontaneous or traumatic in its origin. In the latter case, it may 
be due to a wound of the cornea, iris, ciliary body, etc., or it may 
be produced by a simple blow or fall upon the eye (as from a cricket 
or racket ball, a "cat," or a blow from the fist), without any rup- 
ture of the external coats of the eye. The anterior chamber is 
filled with blood, and when this has become partially absorbed, we 
find perhaps that the lens has been dislocated, and that there is also 
hemorrhage into the vitreous humor. Spontaneous hypsemia is of 
rare occurrence. It has been known to occur periodically during 
the time of menstruation, perhaps vicariously, or after the catame- 
nia have ceased. Cases have been recorded in which the patient 
could voluntarily produce an effusion of blood into the anterior 
chamber by stooping or rapidly shaking his head. 1 The best treat- 
ment is the application of a firm compress bandage to the eye, for 
this accelerates the absorption of the blood more than any other 
remedy. If there is much irritability of the eye or any iritis, atro- 
pine drops should be frequently applied. 

Foreign bodies, such as portions of metal, gun cap, splinters of 
glass, eyelashes, etc., may penetrate the cornea and become lodged 
in the anterior chamber, lying either free in it, or being perhaps 

1 For cases of this kind, vide "A. f. 0.," vii. 1, 65; Wallter, "System der 
Chirurgie," 1848; also Mooren, op. cit. 



206 DISEASES OF THE IRIS. 

partly adherent to the cornea or the iris, and partly situated in 
the anterior chamber. Their presence in the latter frequently sets 
up severe iritis or irido-choroiditis. But in other cases, after the 
immediate effects of the injury have passed away, the foreign body 
may remain for many years innocuous in the anterior chamber, 
without either provoking any serious injury to the affected eye, or 
symptoms of sympathetic disease in the other. Thus Saemisch 1 re- 
cords a case in which a fragment of stone remained twelve years 
in the anterior chamber without exciting any serious injury. The 
foreign body had originally become lodged in the lens, the latter 
became absorbed, and then the fragment of stone fell into the an- 
terior chamber, remaining attached to the secondary cataract by a 
fine filament. As it had set up some irritation a fortnight before 
the patient consulted Saemisch, the latter extracted it successfully 
by a large linear incision in the cornea combined with an iridec- 
tomy. Wecker 2 extracted with success a fragment of stone which 
had remained fourteen years in the anterior chamber, without 
causing any irritation. 

In removing these foreign bodies from the anterior chamber, 
care must be taken that the incision in the cornea is of a sufficient 
size, and so situated, that the foreign body can be easily reached ; 
a large iridectomy should then be made, and the foreign body 
seized with the iridectomy forceps or an iris hook, and extracted. 
If the foreign body {e.g., a splinter of steel) is partly in the cornea 
and partly in the anterior chamber, the blade of the iridectomy 
knife or of the broad needle should be passed behind it, so as to 
steady it and push it forward through the cornea, when its an- 
terior extremity should be seized with a pair of forceps, and then 
it can be readily extracted. 

Cysticerci are sometimes met with in the anterior chamber, and 
about twenty cases of this kind have been recorded by different 
authors. The diagnosis is not difficult, for the little animal is 
noticed in the form of a small transparent vesicle, generally lying 
upon the surface of the iris. The vesicle shows at times very de- 
cided movements, more especially when the pupil is stimulated 
to active contraction by the action of strong light, the head and 
neck of the animal being then perhaps stretched out and moved 
about. The cysticercus may either lie free in the anterior chamber, 
or be partly adherent to the iris or cornea. The following case of 
Mr. Pridgin Teale's 3 illustrates admirably the symptoms presented 
by the presence of a cysticercus and the mode of treatment to be 
adopted : " Mary Isabel Bateman, set. 10, living at Anerley, was 
brought to me on June 2d, in consequence of tenderness of the 
right eye. On examining the eye there was seen (vide Fig. 83) 
on the surface of the lower part of the iris an opaque body, con- 
stricted in the middle, and rather longer than a hemp seed, 
which was evidently causing some distress to the eye. The con- 

' "Klin. Monatsblatter," 1865, 46. * » Klin. Monatsbl." 1867, 36. 

a " R. L. O. H. Rep.," V. 320. 



I RID O -CHOROIDITIS. 



207 




junctiva was slightly injected, the cornea 
was bright, but dotted on its posterior sur- 
face with minute spots, as in corneo-iritis ; 
the iris was active, except at the situations 
of the white body, near which it was ad- 
herent to the capsule of the lens. Tension 
normal. Reading No. 16 Jager." The 
mother stated that for two or three years 
the eye had been occasionally inflamed. 
Six weeks ago she first noticed a speck on 
the iris, about the size of a pin's head, 
which became doubled in size at the end 
of five weeks. The child had always been delicate, and had 
long suffered from threadworms, but never from tapeworm. On 
June 9 th Mr. Teale made an incision at the margin of the cornea 
with a cataract knife and 
withdrew the piece of iris 
on which the animal was 
fixed, and cut it off without 
destroying the cysticercus. 
"When removed from the eye, 
the slow movements of the 
body and changes of shape 
were easily detected. On 
examination with the micro- 
scope, the head and neck, 
surmounted by the circle of 
hooklets and four suckers, 
were seen to project from the 
side of the body (vide Fig. 84). 
The removal of the cysti- 
cercus was soon followed by 
the disappearance of all symp- 
toms of inflammation and 
irritability of the eye, and four months afterwards the patient was 
able to read Jager No. 1. 




10.— IRIDO-CHOROIDITIS. 

I have already pointed out, when speaking of iritis, that on ac- 
count of the close relationship between the iris, ciliary body, and 
the choroid (which in truth form one continuous tissue, the uveal 
tract), any inflammation commencing in the iris is very prone to 
extend to the ciliary body and choroid, or vice versa. The most 
frequent cause of such an extension of the inflammation of the iris 
to the choroid is to be sought in the presence of considerable pos- 
terior synechise, or still more in complete exclusion of the pupil. 1 

1 I must remind the reader that by this term "exclusion of the pupil" is meant, 
that the adhesion between the edge of the pupil and the capsule of the lens extends 



208 DISEASES OP THE IRIS. 

In such cases, the recurrence of the inflammation, and its extension 
to the ciliary body and choroid are partly due to the constant irri- 
tation and teasing kept up by the adhesions at the edge of the 
pupil, preventing the normal dilatations and contractions of the 
pupil, which take place in accordance with any alteration in the 
degree of illumination, the movements of the eye, and the changes 
in the accommodation. Bat it is still more caused by the inter- 
ruption in the communication between the anterior and posterior 
chamber (in cases of exclusion of the pupil), which prevents that 
regulation and just balance of the intra-ocular tension in front and 
behind the iris, which always exists in the healthy eye.- Thus, if 
there is any increase in the vitreous humor, the anterior chamber 
becomes narrower, and contains less aqueous humor; if, on the other 
hand, the quantity of the aqueous humor is increased, the iris is 
somewhat cupped backwards, and the fluid in the posterior chamber 
diminished in quantity. In this way, changes in the amount of 
the fluids in different parts of the eye are prevented from exercising 
any deleterious influence, if their augmentation does not exceed a 
certain degree. For on account of the regulation between the an- 
terior and posterior chamber, no harm accrues. But it is quite 
different when this communication is stopped, and the iris forms, 
so to say, a firm barrier between the anterior and posterior chamber. 
For if there is any increase of tension in the posterior portion of 
the eye, it cannot then be relieved at the expense of fluid in the 
anterior chamber, consequently a stasis occurs in the circulation of 
the inner tunics of the eyeball, which i| soon followed by inflam- 
matory complications of a serious nature. 

In practice we can distinguish two principal forms of irido-cho- 
roiditis, presenting certain characteristic differences, which it is of 
consequence to observe, not only with regard to the prognosis, but 
also with regard to the line of operative treatment which is required 
in each. 

In the first form the disease commences with iritis, and if the 
pupil is not kept widely dilated with atropine, posterior synechias 
soon form and rapidly lead to exclusion of the pupil from circular 
synechia. The pupil may remain clear excepting just at its edge, 
where it shows a well-marked border of pigmented exudation. 
Gradually we notice that small knob-like bulgings show themselves 
in the iris, which may remain chiefly confined to one portion, or 
extend more or less to the whole of it, so that the iris is bulged 
forward into numerous prominences, like sails before the wind. 
This bulging is not due to any firm exudation on the posterior 
surface of the iris, but to a serous effusion behind it ; and the 
partial bulging is due to the fact that some portions of the iris 

completely round the circumference of the pupil, and thus shuts off the communi- 
cation between the anterior and posterior chamber. The area of the pupil may, 
in such a case, be perfectly clear and unoccupied by lymph. If this is not the case, 
but it is filled with a deposit or plug of lymph, it is termed " occlusion" of the 
pupil, and this involves also exclusion. 



IRIDO-OHOKOIDITIS. 209 

resist the pressure of the fluid more than others. The appearance 
presented by such cases is very peculiar and characteristic. 

On account of the firm adhesion of the whole circumference of 
the pupil to the capsule, the iris cannot at this point yield to the 
pressure of the fluid behind it, but bulges out between the pupil 
and its ciliary adhesion into more or less numerous, knob-like pro- 
tuberances, which are sometimes so considerable in size, as to come 
in contact here and there with the posterior surface of the cornea. 
The bulge slopes gradually down towards the circumference of the 
cornea, but passes steeply down to the pupil, which lies in a crater- 
like depression. 

The iris is mostly very much discolored, and of a gray ash-like, 
or greenish tint. On closer examination, more especially with the 
oblique illumination, it will be seen that its fibrillse are somewhat 
opened up and stretched apart, and that it is traversed by a few 
dilated tortuous veins. 

The tension of the eye is generally at first normal, but may then 
become considerably increased, finally however it diminishes more 
and more as the eye becomes atrophied. If the pupil is clear, the 
sight may at the outset be good, but when the bulging of the iris 
occurs, it rapidly deteriorates. If the refractive media and, the 
pupil are sufficiently clear to permit of an ophthalmoscopic exami- 
nation, the vitreous humor is often seen to be diffusely clouded, 
with delicate, floating, or fixed opacities suspended in it, proving 
that the disease is no longer confined to the iris, but has extended, 
to the ciliary body and choroid. If an iridectomy is made in such 
a case, we notice that wheu the knife is withdrawn, some aqueous 
humor escapes from the anterior chamber ; but that the latter is 
not emptied completely, in consequence of the intra-ocular pressure 
not being able to affect the anterior chamber on account of the 
exclusion of the pupil. A sufficiently large piece of iris can gene- 
rally be seized with the forceps and excised, a copious stream of 
watery yellow fluid simultaneously escaping from behind it. The- 
iris now at once recedes to its normal plane, even although, as^ 
Von Graefe points out, the bulging part itself has not been excised, 
but only a neighboring portion of iris. The artificial pupil thus 
obtained, may be almost entirely clear, excepting just at the edge 
of the pupil ; or, as frequently occurs, a more or less considerable 
portion of the uvea is found to be left behind in it ; the uvea 
having been separated from the iris proper by the fluid, and become 
attached to the capsule of the lens. 

The second form of irido-choroiditis presents very different appear- 
ances. The iris, instead of being arched forward in little knob-like 
projections, is perfectly straight and even on its surface, although 
it is pressed forward towards the cornea, producing great shallow- 
ness of the anterior chamber, but the pupil is not drawn back. 
There is complete exclusion of the pupil, and its area is generally 
occupied by a more or less dense false membrane, or by a thick 
plug of lymph. The tissue of the iris looks stretched, its fibrillse 
are indistinct, its surface discolored, and of a dirty reddish tint,. 
14 



210 DISEASES OF THE IRIS. 

which is partly clue to the cloudiness of the aqueous humor, but 
chiefly to the numerous large tortuous bloodvessels which traverse 
its surface ; there being a considerable stasis in the venous circula- 
tion and mechanical hyperemia, on account of the inflammatory 
affection of the ciliary body and choroid. The pressing forward 
of the iris is not due to a collection of fluid behind it, but to the 
pushing forward of the lens (with whose capsule the iris is inti- 
mately connected by means of extensive, thick masses of exudation), 
which yields to the intra-ocular pressure. The false membrane be- 
hind the iris is generally very considerable, consisting of a thick, 
organized, felt-like mass of exudation, which adheres closely to the 
capsule of the lens, and perhaps fills up a great portion of the pos- 
terior chamber. The intra-capsular cells generally proliferate, and 
become clouded, but the lens itself often remains transparent. 

In these cases, a simple iridectomy is of no avail, for even if we 
can remove a portion of the iris (which is often very difficult), the 
opening thus made is again rapidly closed by exudation, for the 
operation excites a fresh attack of inflammation, and finally such 
eyes will undergo gradual destruction from atrophy, if they are not 
operated upon in the manner described below. 

I must state that the distinctive characters of these two forms of 
irido-choroiditis are not always so strongly marked, for we often 
meet with mixed forms ; or, again, the second may supervene upon 
the first, forming, so to say, a more advanced and hopeless stage. 

It has been stated above, that irido-choroiditis may ensue upon an 
inflammation which primarily affected the iris and then extended 
to the ciliary body and choroid ; or that it may begin in the latter, 
and only subsequently attack the iris. It is sometimes difficult, at 
a late stage of the disease, to ascertain with anything like certainty, 
which course the disease had originally pursued. The following 
facts will, however, afford us some guidance. "When the disease 
originated in the iris, we find that there were well-marked symp- 
toms of recurrent inflammation, and that the structure of the iris is 
considerably changed, being much discolored, thinned and atro- 
phied. The lens also becomes less frequently opaque, and only at 
a much later period. The dimness of sight is likewise less consider- 
able, and depends at first chiefly upon the deposit of lymph in the 
pupil, and only subsequently upon the cloudiness of the lens or 
vitreous humor. Whereas, if the inflammation commenced in the 
• choroid, the train of symptoms is different. There are marked 
symptoms of choroiditis, with opacity of the vitreous humor, fol- 
lowed very generally by detachment of the retina, from a serous or 
hemorrhagic effusion. The tension of the eyeball diminishes. 
Then an opacity of the lens supervenes, very frequently commencing 
at its posterior pole, and gradually extending thence to the whole 
lens substance. At a later stage, the lens undergoes further degene- 
rative changes, becoming chalky, and transformed into a " cataracta 
accreta." The iris may not be affected until a late period of the 
disease, and not until some time after the formation »f cataract, or 
it may become inflamed at an earlier stage ; but the iritis is gene- 



IRIDO-CHOROIDITIS. 211 

rally insidious, and not accompanied by any marked inflammatory 
symptoms. The pupil becomes adherent, lymph is effused in its 
area and on the posterior surface of the iris, which may become 
bulged forward by fluid, or pressed forward by dense masses of 
exudation. Two very important guides by which to distinguish 
between this form of irido-choroiditis and that commencing with 
an inflammation in the iris, are the degree of sight and the state of 
the field of vision. The perception of light will be far less in the 
former case, and there will be a marked contraction or absence of 
that part of the field (the upper) which corresponds to the detached 
portion of the retina. Thus, if the light from the lamp is distin- 
guished when it is held in the lower half of the field, but becomes 
invisible when it is removed into the upper half, it indicates a 
detachment of the lower portion of the retina. 

The sight is generally very much impaired in cases of irido-cho- 
roiditis so that the patient can only perhaps distinguish large letters, 
count fingers, or has only simple perception of light. In irido-cho- 
roiditis uncomplicated by detachment of the retina, or glaucomatous 
or atrophic changes in the retina and optic nerve, the quantitative 
field of vision should be good. 

The prognosis is, of course, very variable, according to the stage 
and form of the disease. If a case of irido-choroiditis (uncompli- 
cated with extensive lesions of the choroid, detachment of the re- 
tina, or opacity of the lens) be seen at the outset, whilst the changes 
in the iris are still but slight, the area of the pupil clear, or only 
occupied by a film of exudation, and there are no masses of exuda- 
tion membranes behind the iris, the prognosis may be favorable if 
" the sight be still tolerably good, and the field of vision normal. 
The first form of irido-choroiditis, in which the iris is bulged 
forward by fluid, affords a much better prognosis than the second. 
The most hopeless of all are of course the cases of irido-choroiditis 
with detachment of the retina. In such a case, or if there is no 
perception of light left, no operation should be attempted excepting 
for the sake of relieving pain, or diminishing the risk of sympa- 
thetic ophthalmia. A certain degree of atrophy of the eye (if it be 
not too far advanced, and the perception of light and field of vision 
are good) does not contra-indicate an operation, for we find that 
the iridectomy often arrests the atrophy, and that the eye regains 
its plumpness, and a normal degree of tension. 

The most frequent cause of irido-choroiditis is the presence of 
posterior synechiee, above all, the circular form. The presence of 
adhesions between the edge of the pupil and the capsule of the lens 
leads to frequent recurrences of the iritis, more lymph is effused, 
more synechias formed, until finally the pupil is excluded, and then, 
if this has not already occurred, future inflammations are sure to 
extend from the iris to the ciliary body and the choroid. The best 
safeguard against a recurrence of the iritis and the supervention of 
irido-choroiditis, is to cure a case of iritis without the formation 
of any posterior synechise. Of course, such eyes do not enjoy a 
perfect immunity from a recurrence of iritis if a sufficient exciting 



212 DISEASES OP THE IBIS. 

cause should arise, but they are far less prone to it than if adhesions 
have remained behind. Irido-choroiditis may also be caused by 
injuries and wounds of the eye, by the lodgment of foreign bodies 
(more especially splinters of metal, gun caps, or glass) within the 
eye, and by operations, particularly those for cataract. It may 
likewise arise in consequence of an injury to the other eye, thus 
constituting " sympathetic ophthalmia." 

If the adhesions between the iris and capsule of the lens are not 
considerable, and are thin and "tongued," it maybe possible to tear 
them through by the prolonged use of a strong solution of atropine, 
or to separate them by operative interference (corelysis). But if 
they are firm and broad, and especially if they extend all around 
the edge of the pupil, and thus cut off the communication between 
the anterior and posterior chamber, we must have recourse to iridec- 
tomy ; for no other means will suffice to guard the eye against the 
dangers of irido-choroiditis, or to stay the progress of this disease 
if it is already present. 

In the early stage, when the adhesions are not very extensive 
and firm, and the tissue of the iris has not yet undergone atrophic 
changes, it is generally not difficult to obtain a tolerably good arti- 
ficial pupil, by means of an iridectomy. Frequently, however, a 
small rim of iris, at the edge of the pupil, is so firmly attached to 
the capsule as not to yield to the traction of the forceps, but is left 
standing. This does not invalidate the result, if a tolerable sized 
piece of iris is removed, and a. clear artificial pupil and a free com- 
munication between the two chambers are established. If the pupil 
is only adherent at certain points, it will be best to employ a fine 
blunt hook, instead of the iris forceps, for catching up the iris. 
The hook is to be passed carefully along to the edge of the pupil 
(the portion where there are no synechia), gently turned over the 
margin, and the iris then drawn out and snipped off. In this way, 
we may often succeed in excising a considerable segment of the iris, 
whereas from the rottenness of its structure and the firmness of 
the adhesions, it would probably have resisted the grasp of the 
forceps, and only small shreds have been removed. Care must be 
taken never to employ too much force in the removal of the iris, 
otherwise a dialysis may be easily produced at the opposite circum- 
ference of the iris. 

We generally find that after the operation, the inflammatory 
symptoms quickly subside, that the sight improves, and that the 
recurrence of inflammation is arrested. In some cases, however, 
this is not the case. Exposure to cold, bright light, continued use 
of the eyes, easily reproduce an inflammation. If these recurrences 
are frequent and obstinate, much benefit is often derived from a 
second iridectomy, made in an opposite direction, so that the two 
halves of the iris are completely cut off from each other. This 
operation has been practised with much success by Graefe and 
Critchett (independently of each other), and I have often found 
much benefit from its performance in cases of obstinate recurrent 
iritis. The line of the double iridectomy may be either horizontal 



IRIDO-CHOROIDITIS. 213 

or vertical. The advantage of the latter is, that a more or less 
considerable portion of the upper part of the artificial pupil is 
covered by the upper lid, which diminishes the circles of diffusion 
upon the retina. 

In that form of irido-choroiditis, in which the iris is bulged 
forward by knob-like protuberances, and the edge of the pupil is 
tied down tightly by a firm circular synechia, it is generally not 
difficult to grasp and remove a considerable piece of iris, and thus 
to form a good-sized artificial pupil. 

On account of the great shallowness of the anterior chamber and 
the proximity of the bulging iris to the posterior portion of the 
cornea, it is often very difficult to avoid cutting the iris with the 
common iridectomy knife. It is better, therefore, to make the in- 
cision with Von G-raefe's long, narrow cataract knife, for with it 
we can skirt the edge of the chamber, and gain a large incision 
without any fear of injuring the iris. 

We unfortunately not unfrequently find that although the iridec- 
tomy is large, the sight is but little if at all improved, for the arti- 
ficial pupil is occupied by a thick uveal membrane detached by 
the fluid from the iris. It is of practical importance to remember 
the probability of this occurrence on forming our prognosis as to 
the effect of the operation ; hence we should never definitively 
promise the patient great improvement of sight after the first ope- 
ration, but prepare him for the probable necessity of a second. The 
uveal pigment is so intimately connected with the capsule of the 
lens, that it is generally unwise to attempt to scrape a portion of 
it off, as rupture of the capsule and traumatic cataract might ensue. 
If we therefore find that so considerable a portion of the artificial 
pupil (the natural one being also blocked up by lymph) is occupied 
by the uvea as greatly to impair the sight, it will be best, at a 
later period, to make another iridectomy in a different direction, 
in the hope that at this point there may be less deposit upon the 
capsule. By this means, or even by a third iridectomy, we may 
succeed in finally giving the patient a good clear pupil and a con- 
siderable degree of sight. A most interesting and instructive ex- 
ample of this kind occurred amongst the patients at Moorfields, 
where Mr. Bowman repeated the operation ; performing iridectomy 
twice upon the right eye and three times upon the left. The result 
was most successful. On the patient's admission his sight was as 
follows: Right eye, letters of 20 (Jager) with difficulty, counts 
fingers within 18 inches. Left eye — counts fingers with uncertainty 
within 3 feet. Seven weeks afterwards, on his discharge from the 
hospital, he could read No. 2 with the right eye, and No. 12 with 
the left. 1 

Even although the first iridectomy may not materially improve 
the sight, we find that it generally exerts a beneficial influence 
upon the tissue of the iris and the general condition of the eye ; 

1 I have reported this case at length in the "Royal London Opkth. Hosp. 
Reports," vol. iii. 



214 DISEASES OF THE IKIS. 

the iris gradually gaining a more normal color and appearance. 
Von Graefe was the first to call attention to the fact that a certain 
degree of atrophy of the eye, consequent upon irido-choroiditis, may 
be arrested by the performance of iridectomy, and the eye regain ' 
its normal tension.- This fact has since been widely acknowledged 
by all surgeons who have much experience on this subject. Of 
course, the atrophy must not have advanced too far, otherwise its 
arrest will be impossible, the same being the case if detachment of 
the retina has occurred. The benefit derived from iridectomy 
(perhaps repeated several times) in these cases, is that the stasis 
and congestion in the choroidal vessels are relieved, Avhich not only 
causes an improvement in the choroidal circulation, but also in the 
nutrition of the vitreous humor. 

If we cannot succeed in finding a portion of capsule sufficiently 
clear of uveal pigment to allow of much improvement of sight, or 
if the lens is opaque, it will be best to remove the latter. 

Whilst we may afford considerable improvement in the above 
class of cases from repeated iridectomies, this is by no means the 
rule in the second kind of irido-choroiditis. Although in the 
former case the first artificial pupil often becomes narrowed or 
even closed, yet the texture of the iris improves ; at a second ope- 
ration we mostly succeed in gaining a larger pupil, and at a sub- 
sequent one, a tolerably good result as to the sight. But when 
thick felt-like masses of exudation exist between the iris and 
capsule, we fail to remove a considerable portion of the rotten iris, 
and this attempt, moreover, sets up renewed inflammation, in- 
creased proliferation of the exudation masses, and we thus, instead 
of improving the condition, hasten the atrophy of the eye. It will 
therefore be necessary, in order to benefit such cases, to remove 
not only the iris but the dense masses behind it ; but they are 
generally so firmly adherent to the capsule that we are almost sure 
to rupture the latter in our endeavor to remove them. A trau- 
matic cataract is formed, if the lens is not already opaque, and 
this complicates matters still more. But Von G-raefe had an op- 
portunity of seeing that these false membranes could be removed 
with comparative facility and success when the lens was absent. 1 
This led him to remove the lens, prior to attempting the with- 
drawal of the iris and exudation masses. In these cases Von 
Graefe now operates in the following manner:' With his narrow 
cataract knife he makes the section just as in his operation for 
cataract, with the exception that, directly the puncture is made, 
the blade is passed straight through the iris, and brought out at the 
counter puncture, thus freely dividing the iris. This generally 
causes such a wide laceration of the capsule, that the lens matter 
exudes even while the section is being made. A pair of firmly- 
catching, cross-grooved forceps is then passed into the incision, and 

' " A. f. 0," 6, 2, 97. Vide also the author's abstract of this paper, " R. L. 0. 
H. Rep.," iii. 224. 
2 "A. f. 0.," 14,3,141. 



IRIDO-CHOROIDITIS. 215 

one blade pushed boldly forward between the iris and cornea, and 
the other behind the retro-iritic masses of exudation ; the iris and 
portions of false membrane which are thus grasped, are then to be 
gently drawn out. If they do not come readily, their removal may 
be facilitated by making a cut with the scissors at each extremity 
of the linear incision, which had been made through the iris with 
the knife. The removal of the iris and false membrane is often 
followed by the escape of the remaining portion of the lens, in 
which case the operation may be regarded as completed. If this 
does not take place, the capsule should be freely lacerated with the 
pricker (cystotome), and the lens evacuated by a slight pressure 
of the curette on the cornea, just as in Von Graefe's operation for 
extraction of cataract. Should some opaque portions of capsule 
remain behind in the lower portion of the pupil after the removal 
of the lens, they are to be seized with the grooved forceps and 
gently removed, if they are not too firmty adherent to the iris or 
ciliary processes. If the lens is chalky, Von Graefe passes in a 
curved hook, and, pressing this somewhat on the anterior capsule, 
endeavors to free the lens from any adhesions, and thus make it 
sufficiently moveable to escape through the section by a little 
pressure of the curette on the cornea. He, however, strongly 
objects, even in these cases, to the introduction of any instrument 
(e. g., a scoop) behind the lens. 

As the success of the iridectomy and of the extraction of the lens 
in cases of irido-choroiditis is often invalidated by the contraction 
and subsequent closure of the artificial pupil, Mr. Bowman has 
devised the following operation, termed by him, " excision of the 
pupil," which has afforded favorable results : The puncture and 
counter-puncture may be made as in Von Graefe's operation for 
extraction of cataract (and with the same knife). The incision is 
not, however, concluded, but a narrow bridge is left standing at its 
apex, which aids in preventing the escape of the vitreous. The 
blades of a pair of fine scissors are then introduced through the first 
incision (the puncture), and the one blade (blunt-pointed) passed in 
front of the iris ; the other, which is sharp, pierces the iris and 
anterior capsule of the lens, and running down in front of the nu- 
cleus, and without moving it from its bed, a cut is made diagonally 
downwards as far as the centre of the lower part of the iris. The 
scissors are then withdrawn, and next introduced through the 
counter-puncture, and a similar incision made on this side, so that 
the two incisions meet at the lower part of the iris, including be- 
tween them a large triangular piece of iris as well as the constrictor 
pupillse. Finally the base of the triangle is divided by cutting 
through the upper portion of the iris lying between the puncture 
and counter-puncture, and the whole triangular piece is then re- 
moved, as well as any false membrane attached to it, with a pair of 
forceps. The bridge of cornea is then divided, and the lens re- 
moved in the usual manner. The operation has been varied by Mr. 
Bowman in two or three ways, according to the cases dealt with. 
"When there is no lens to be removed, the bridge of cornea is not 



216 DISEASES OF THE IBIS. 

divided, as the operation is already complete. Sometimes the cut 
across the base of the iris or the third above described, is not neces- 
sary, as the triangular portion of iris, including the pupil and cap- 
sule, admits of being easily torn off along the ciliary attachment. 
It is when there is a very dense and tough capsule or false mem- 
brane behind the iris, that the third incision with scissors is chiefly 
required, as avoiding the dangerous dragging of the ciliary struc- 
tures. In other instances, the entire section of the cornea has been 
made at one stroke, without leaving the temporary bridge. 

Mr. Bowman has also applied the same mode of operating to cases 
of dense membranous obstruction of the iris region, where the lens 
has been previously removed, and to these he considers it to be par- 
ticularly applicable, especially if its performance be delayed until 
all signs of inflammatory tendency have entirely disappeared. 



11.— SYMPATHETIC OPHTHALMIA. 

The name of "sympathetic ophthalmia" was first applied by 
Mackenzie to those cases in which an injury of the one eye was fol- 
lowed by a peculiar inflammation in the other, which generally 
ensues within a short time of the accident, and proves extremely 
dangerous and intractable. That such a sympathy exists between 
the two eyes had, however, been previously pointed out by Himly 
and Beer. 

The character of sympathetic inflammation is so extremely dan- 
gerous and insidious, that if it has once been lit up, we are but 
seldom able to stay its progress before great, and often irreparable, 
mischief, has been done. In the great majority of cases, the dis- 
ease shows itself in the form of a very malignant irido-cyclitis, 
accompanied by great degeneration of the iris, total exclusion of the 
pupil, and the formation of dense masses of exudation between the 
posterior surface of the iris and the capsule of the lens. This is the 
" sympathetic ophthalmia" -par exceUence,hut it occasionally appears 
in a more tractable and benign form, assuming the character of 
serous iritis. Von G-raefe has, moreover, observed a third and still 
more rare affection, viz., sympathetic choroido-retinitis. 

. It is of practical importance to distinguish the condition of sym- 
pathetic irritation, which sometimes ensues upon an injury or in- 
flammation of the one eye, from sympathetic ophthalmia. In the 
former case, the patient finds that any inflammatory exacerbation 
of the injured eye is accompanied by more or less irritability of the 
other. He is unable to employ the latter in reading or fine work, 
without its soon becoming tired and strained, owing to an impair- 
ment of the power of accommodation. The range of accommodation 
is generally also markedly diminished, the near point being removed 
further from the eye. Every accommodative effort causes the eye 
to flush up and become irritable, a bright rosy zone appears around 
the cornea, and photophobia and lachrymation soon supervene, 
together with more or less ciliary neuralgia. These symptoms 



SYMPATHETIC OPHTHALMIA. 217 

generally subside, more especially at the commencement, as soon as 
the work is laid aside, but quickly reappear on its being resumed, or 
when the eye is exposed to cold, bright light, etc. The injured eye, 
moreover, often also becomes painful and irritable, when the other 
is used for reading or sewing. Bonders describes a form of severe 
sympathetic irritation under the name of " sympathetic neurosis." 
It is particularly distinguished by the intensity of the photophobia 
and lachrymation, these symptoms being often so severe as to cause 
a violent spasm of the lids, and directly any attempt is made to 
open the eye, a stream of scalding tears pours over the cheek. 
There is, however, no impairment of sight, although from its great 
irritability the eye is quite unfit for use. Donders considers that 
this neurosis never passes over into sympathetic ophthalmia, and 
yields in a very rapid and marked manner to the removal of the 
injured eye. Whether or not cases of sympathetic irritation are to 
be regarded in the light of a premonitory stage of sympathetic 
ophthalmia, or whether they are to be looked upon as completely 
differing from it in character, and as never liable to pass over into 
it, is at present, I think, an open question. Whilst on the one hand, 
it must be admitted that we occasionally meet with instances in 
which a state of great irritability has existed for a long time with- 
out setting up sympathetic ophthalmia, yet on the other, it must also 
be conceded, that the attack of inflammation is often shown to 
have been clearly preceded by symptoms of irritation. Although 
this question is one of much interest and importance in the study 
of the true nature of sympathetic inflammation, it is fortunately of 
but little consequence in the treatment. For I think there can be 
no doubt that the proper mode of dealing with a case in which 
marked and persistent symptoms of sympathetic irritability appear, 
is the immediate removal of the injured eye, more especially if its 
sight is lost or very much impaired. Indeed, it would be incurring 
unnecessary risk to neglect doing so, on the supposition that the 
state of irritation would never pass over into that of inflammation. 
Sympathetic irido-cyclitis is characterized by all the symptoms of 
a severe intra-ocular inflammation. The eyelids are somewhat red 
and swollen, and there is more or less photophobia, lachrymation, 
and ciliary neuralgia. Sometimes, however, there is not the 
slightest pain, so that even in children we hear no complaint, and 
this invests the disease with a peculiarly dangerous character, as 
it is very apt to be long unnoticed by the parents. The ciliary 
region is generally sensitive to the touch, and often acutely so. 
Soon there appear some peri-corneal vascularity and chemosis, the 
iris becomes discolored, and of a- yellowish-red tint, the aqueous 
humor is clouded, and the anterior chamber perhaps diminished 
in depth. There is a rapid effusion of lymph at the edge of the 
pupil, soon leading to its complete exclusion [Fig. 85] ; indeed 
the action of atropine exerts but little influence upon the pupil. 
The exudation is not, however, confined to the pupillary edge, 
but extends to the posterior surface of the iris and the ciliary 
processes. The iris becomes firmly glued down to the capsule of 



218 



DISEASES OF THE IBIS. 




the lens, and, as the disease advances, these exudations assume a 
very dense, firm, and organized character. Lymph is also effused 

upon the surface and into the 
stroma of the iris, often to such 
an extent, that the latter appears 
soaked in it. The pupil is either 
covered by a film of exudation, or 
may be completely occluded by a 
dense yellow nodule. On account 
of the inflammatory swelling of 
the ciliary body, this region is 



'■ 

^gfpr*^ very sensitive to the touch, and 

After Lawson] the circulation of the iris is greatly 

impeded, and the venous efflux ob- 
structed ; hence we soon notice the appearance of large tortuous 
veins upon the iris. Its structure soon becomes degenerated and 
changed into a firm, tense, fibrillar tissue, which cannot be caught 
up in a fold by the iridectomy forceps, but is so friable and rotten 
that it tears and breaks down under their grasp. Hence if an 
iridectomy is attempted, we shall only succeed in tearing away a 
small portion of the iris, and probably set up fresh inflammation, 
which will lead to a rapid increase in the density and extent of 
the exudation-masses. If the pupil and refracting media are suffi- 
ciently clear to permit of the use of the ophthalmoscope, we may 
notice opacities in the vitreous humor, and inflammatory changes 
in the choroid and retina. Or there may be dense masses of exu- 
dation in the anterior portion of the vitreous humor, giving rise 
to a peculiar yellow, lustrous reflex. At a later stage of the dis- 
ease, when the morbid products have become more consolidated, 
the periphery of the iris is often drawn back, which is due to a 
direct retraction caused by the adhesion of its posterior surface to 
the ciliary processes (Graefe 1 ). Whereas, on account of the increase 
in the exudation behind the iris, the latter, and with it the lens, 
is moved forward. So that the more central portion of the iris and 
the pupil are approached nearer the cornea, and the anterior chamber 
narrowed, whilst the periphery of the iris may be drawn back to- 
wards the ciliary body. In other cases, fluid is effused behind the 
iris, and the latter becomes bulged out into little protuberances. 
The attack is often so insidious and painless, that the patient pays 
but little heed to the first stage of the inflammation, thinking per- 
haps that he has only caught a slight " cold" in the eye ; and it is 
not till the sight becomes materially affected, that he is frightened 
and seeks medical aid. In children especially (from their taking 
but little heed of the impairment of sight and from the absence of 
pain) the disease is sometimes allowed to proceed very far indeed 
before much attention is paid to it by the parents. But although 
the spontaneous pain is often absent, we find that the region of 
the ciliary body is generally very sensitive to the touch, and some- 



1 "A. f. 0.,"xii. 2, 151. 



SYMPATHETIC OPHTHALMIA. 219 

times, as has been pointed out by Bowman and Von Graefe, at a 
spot corresponding symmetrically to the point at which the other 
eye has beep injured, or where it still remains tender to the touch. 

The tension of the eye varies considerably ; at first, it is gener- 
ally more or less increased, but then it gradually diminishes until 
the eye becomes quite soft, being still, however, liable to consider- 
able fluctuations in consistence. It is, moreover, a fact of great 
practical importance, that if such eyes are left alone, and the acme 
of the inflammatory process is alloAved to subside, and the eye to 
become quiet, that gradually and slowly its condition often begins 
to improve. The tension becomes better, and gradually augments 
until it may even reach the normal standard ; the tissue of the iris 
improves greatly in appearance, loses its dirty yellow hue, and 
assumes a fresher and more normal tint. 

In the sympathetic serous iritis we find that the symptoms are 
very different, and closely resemble those of serous iritis, or serous 
irido-cyclitis. Together with a certain degree of ciliary injection, 
we notice that the iris is somewhat discolored, the pupil perhaps 
dilated, the aqueous humor faintly clouded, and the posterior 
surface of the cornea dotted by innumerable, small, punctiform 
opacities, which are perhaps arranged in the form of a pyramid, 
having its base downwards. The depth of the anterior chamber 
may be increased. If the inflammation has extended to the ciliary 
body, this is sensitive to the touch, and the vitreous humor is 
likewise clouded, more especially if there is also choroiditis. The 
intra-ocular tension is often augmented.. This form is much less 
common, and much less dangerous than sympathetic irido-cyclitis, 
but it may pass over into the latter. 

According to Mooren, 1 the cases in which the sympathetic in- 
flammation commences in the iris afford a more favorable prognosis 
than if it starts from the choroid, the worst form being where it 
begins in the ciliary body. 

Von Graefe 2 describes another and very rare form of sympathetic 
ophthalmia, under the name of " sympathetic choroido-retinitis," and 
narrates two cases, illustrative of the symptoms presented by it. 
In one of these, the patient had a dislocated chalky lens lying in 
the anterior chamber of the left eye, which was perfectly blind, 
and somewhat atrophied. The lens was removed with facility by 
Von Graefe, but the operation was accompanied by a considerable 
loss of fluid, yellow vitreous humor. The eye remained irritable, 
red, and very sensitive to the touch for several weeks, and there 
were, moreover, symptoms of plastic cyclitis. Six week's after the 
operation, when these symptoms had somewhat subsided, but the 
sensibility to the touch still remained, the sight of the right eye, 
which had hitherto been perfectly good, began suddenly to be im- 
paired, but this was unaccompanied by any pain. The acuity of 

1 Vide Mooren's very interesting and valuable work, " Ueber Sympathisclie 
Gesichtsstorungen," p. 92. Berlin, Hirschwald, 1869. 
8 "Arcliiv. f. O.," xii. 2, 171. 



220 DISEASES OF THE IRIS. 

vision had already on the second day after the attack sunk to one- 
fifth, and there was considerable torpor of the retina, with indis- 
tinctness of eccentric vision in the whole of the temporal half of 
the visual field. With the ophthalmoscope, the retinal veins were 
seen to be very tortuous and dilated, more especially on the inner 
side. The retina also showed a delicate and diffuse cloudiness, 
which not only veiled the choroidal ring of the optic nerve, but 
extended to certain portions of the retina, especially along the 
course of some of the larger retinal vessels. Slight symptoms of 
iritis soon supervened, and very delicate punctiform opacities were 
observed on the membrane of Descemet. The power of accommo- 
dation was almost completely paralyzed. These symptoms gradually 
subsided, and the sight became finally quite restored. Whether 
this favorable result was chiefly due to the remedial measures. em- 
ployed (local depletion, bichloride of mercury, and afterwards 
iodide of potassium), or to the extinction of the sensibility of the 
left eye to the touch, was uncertain. Von Graefe himself lays the 
greater stress upon the last fact. The morbid appearances of the 
retina disappeared less rapidly than the functional disturbances, 
and then there were noticed patches of choroiditis. 

The causes of sympathetic ophthalmia are to be sought in those 
lesions which may set up a plastic inflammation of the ciliary 
body. 1. Amongst the most frequent causes are injuries to the 
eye, such as punctured and incised wounds, more especially in the 
region of the ciliary body. If such wounds are extensive, the lens 
has generally escaped, accompanied perhaps by considerable loss of 
vitreous and extensive intra-ocular hemorrhage. Small incised 
wounds of the ciliary region, or situated partly in the latter and 
partly in the cornea, are not necessarily of so dangerous a character, 
more especially if they have only penetrated the coats of the eye, 
without injury of the lens or vitreous humor. In such cases, no 
time should be lost in bringing the lips of the little wound together 
with a suture. Union by the first intention will take place, and 
many an eye will thus be saved, which might otherwise have not 
only been itself lost from choroiditis, but might have also proved 
a source of danger to the other eye. In wounds which implicate 
the cornea alone, there is generally not much danger of sympathetic 
ophthalmia, although, if they are accompanied by a considerable 
prolapse of the iris, and this is situated near the periphery, it may, 
by dragging upon and irritating the ciliary processes, set up sym- 
pathetic ophthalmia. But when there has been a penetrating 
wound of the cornea (such as may be produced by a pair of scissors), 
and the iris and lens have been also injured, there is always some 
risk. The disease may, moreover, be likewise produced by severe 
contusions of the eye. 

2. Foreign bodies lodged within the eye, are a most frequent 
.cause. Amongst these we must especially enumerate portions of 
gun cap or of metal, and splinters of glass or stone. They prove 
a source of constant irritation to the eye, more especially if they 
are considerable in size, and differ in their chemical constituents 



SYMPATHETIC OPHTHALMIA. 221 

from the structures in which they are imhedded. Inflammation 
of the iris and choroid supervene, and the eye may become gradually 
atrophied, shrinking down to a small shrivelled stump. But even 
then, all danger to the other eye, if this has hitherto escaped, is by 
no means passed, for such stumps are a source of constant risk, as 
long as they remain painful to the touch, and show signs of irrita- 
bility. Years may elapse ■ after the injury, and the patient have 
long since forgotten his surgeon's admonition as to the danger to 
the other eye, when suddenly the latter becomes sympathetically 
inflamed, and, in spite of all our efforts, perhaps destroyed. The 
longest time which I have known to elapse between the injury of 
one eye and sympathetic inflammation in the other is 26 years, 
which occurred in the following ease: 1 J. E.,set. 42, anironfounder, 
came under my care at the Royal London Ophthalmic Hospital, on 
March 2, 1869. He had lost the left eye 26 years ago through an 
injury from a piece of metal; the globe had shrunk down to \ of 
its normal size, and was very painful on pressure. The right eye 
remained perfectly well after the accident until 1860, when it was 
attacked with iritis, for which an iridectomy was performed at 
that time ; it being, however, deemed unadvisable to do anything 
to the left eye. Since the iridectomy in 1860, he had been able to 
follow his occupation up to Christmas, 1868, when this eye again 
became inflamed, and its sight failed more and more. On March. 
2, 1869, it presented the following symptoms: The eye-tension is 
normal, the field of vision complete, but the sight so much im- 
paired that he cannot decipher letters of Jager 20, but only see their 
black outline. The cornea is somewhat hazy, the iris inflamed, 
the pupil clouded, and with the ophthalmoscope hardly any reflex 
can be obtained from the fundus. No relief being experienced 
from the application of atropine and warm fomentations, I urgently 
advised the removal of the left eyeball, to which the patient sub- 
mitted on March 19. A piece of metal was found in it, firmly 
imbedded in a mass of exudation matter (on the inner side of the 
sclerotic), in the centre of a firm fibrous cord, which appeared to 
be the shrunken and disorganized retina. March 23. The right 
eye has improved so much since the extirpation of the other, four 
days ago, that the patient is now able to read words of Jager 16. 
The inflammatory symptoms have greatly subsided, the cornea and 
pupil are clearer, there is still however but little reflex from the 
fundus. March 30. He now reads words of Jager 10. The re- 
fracting media are much clearer and the outline of the optic disk 
can be indistinctly seen with the ophthalmoscope. The patient 
ceased to attend the hospital after this date, and returned to York- 
shire. He writes, however, in the middle of October, that the right 
eye is strong and well, and its sight so much improved, that he is 
able to follow his employment (superintendent of an iron forge). 
Mr. Lawson in his valuable work on " Injuries of the Eye," 2 also 

1 "Lancet," December 18, 1869. 2 P. 321—323. 



222 DISEASES OF THE IRIS. 

narrates two interesting cases in which sympathetic mischief did 
not follow for many years after the injury from a foreign body. 

3. Sympathetic ophthalmia may also be caused by internal in- 
flammations of the eye, more especially if they are accompanied by 
hemorrhagic effusions, either considerable in quantity, or of fre- 
quent recurrence, together with rapid fluctuations in the intra- 
ocular tension. Also if a bony deposit in the choroid has occurred, 
and the eye remains irritable to the touch. Indeed the continu- 
ance of sensibility in the region of the ciliary body in cases of irido- 
choroiditis, or in eyes which have undergone atrophy after internal 
inflammation, is one of the most dangerous symptoms, as such eyes 
are extremely prone to set up sympathetic ophthalmia. The latter 
may also arise in cases of spontaneous detachment of the retina ; 
dislocation, or inclination of the lens ; intra-ocular tumors, if 
secondary irido-cyclitis supervenes ; intra-ocular cysticerci ; also in 
prolapse of the iris causing great traction on the ciliary body, and 
consequently irritation of the ciliary nerves. Hence some surgeons 
never perform iridodesis, for fear of setting up cyclitis, and thus 
perhaps inducing sympathetic ophthalmia. If any of these causes 
set up plastic cyclitis they may give rise to sympathetic ophthalmia. 1 
Indeed Mooren goes so far as to believe " that every inflammation 
in the course of the uveal tract, quite apart from the primary cause 
of its origin, is capable of setting up sympathetic disturbances if 
it manifests itself as a cyclitis from the outset, or as soon as it, in 
the course of time, assumes this character." 2 

It is a very interesting and important fact that Iwanoft', 3 Hirsch- 
berg, 4 etc., found, on examination of some eyes which had been 
excised for setting up sympathetic ophthalmia, that the ciliary 
body had not only undergone inflammation, but had become de- 
tached from the sclerotic, thus causing great stretching and irrita- 
tion of the ciliary nerves, and forming the starting point of the 
sympathetic affection of the other eye. 

Mooren 5 also mentions a very interesting case in which the sym- 
pathetic ophthalmia was apparently produced by the contusion of 
the optic nerve in dividing it with the scissors in excision of the eye. 

It was formerly generally supposed that sympathetic ophthalmia 
was propagated from the injured eye to its fellow through the optic 
nerves, by way of the optic commissure. But this view has been 
long abandoned as untenable, for cases of sympathetic ophthalmia 
have occurred in eyes in which the optic nerves were not only 
completely atrophied, but had even undergone extensive chalky 
degeneration. It is now generally held that the sympathy is pro- 
pagated by the ciliary nerves, and this view certainly receives the 
strongest support from many clinical facts. Thus we not unfre- 

1 Vide also Dr. Laqueur's brochure on " Les Affections sympathiques de l'GEil." 
Bailliere et Fils. Paris, 1869. 

2 Op. cit, p. 58. 

8 "Mooren's Sympathisers Gesichtstorungen," p. 161 

« " Kl. Monatsbl.," Oct. 1869, p. 297. 

6 " Ophthalmiatrische Beobachtungen," p. 160. 



SYMPATHETIC OPHTHALMIA. 223 

quently meet with cases, as has been especially pointed out by 
Bowman and Von Graefe, in which the starting point of the sym- 
pathetic irritation or inflammation in the second eye occurs at a 
spot of the ciliary region which corresponds symmetrically to that 
at which the injured eye was hurt, or at which the ciliary region 
still retains its sensibility to the touch. Moreover, as Von Graefe 
strongly insists, the danger of the sympathetic ophthalmia should 
never be considered as passed, as long as the ciliary region of the 
injured eye, or its stump, remains sensitive to the touch, more 
especially if it is accompanied by diminished tension, for it is then 
a symptom of plastic cyclitis. 

Again, when suppuration of the eyeball occurs, and the ciliary 
nerves are destroyed by it, there is no tendency to sympathetic 
ophthalmia. It is a well-known fact that the latter is never set up 
by eyes lost from general suppuration (panophthalmitis), as, for in- 
stance, after operations. 

The prognosis of sympathetic ophthalmia is most unfavorable, if 
the disease has once fairly broken out. In the stage of sympathetic 
irritation, the removal of the injured eye arrests the progress ; but 
it is quite different if the inflammation has already set in, more 
especially if it assumes the character of plastic irido-cyclitis. For 
then, even the immediate enucleation of the other eye generally 
fails to have any, or any but a temporary beneficial effect. For a 
few days or weeks the inflammation appears to be diminished, but 
then it breaks out again with all its former severity. The serous 
sympathetic iritis, being more benign in character and more amen- 
able to treatment, affords a more favorable prognosis. 

Sympathetic ophthalmia is more prone to attack youthful indi- 
viduals than middle-aged or elderly persons. Its course also appears 
to be more rapid in the young. It generally occurs within a few 
weeks of the injury, but a long period, even many years, may elapse 
before it is excited. 

Treatment. — With regard to the general treatment of sympathetic 
ophthalmia, I must strongly insist upon the necessity of complete 
rest of the eye for a prolonged period, and this is to be continued 
for some length of time after the eye appears to have recovered from 
the inflammatory attack. Otherwise, there is the greatest risk of a 
recurrence, which may prove most dangerous and intractable. 
Whilst the eye remains irritable, the patient should be confined to 
a darkened room, and if he has to go into the open air, the eye 
should either be protected by a bandage, or by a pair of dark blue 
eye protectors, or the wire goggles. In order to allay the irrita- 
bility of the eye, poppy or belladonna fomentations may be applied, 
as also a solution of atropine (varying from ij to iv grains to the 
ounce of water), which should be dropped into the eye several times 
a day. At the very outset of the disease, we should endeavor to 
gain, if possible, a wide dilatation of the pupil, and hence apply it 
more frequently and in a strong solution ; but as has already been 
stated above, the pupil is generally very imperfectly acted upon by 



224 DISEASES OF THE IRIS. 

atropine, and at a later stage, the adhesions to the capsule are so 
firm and extensive as completely to resist its action. 

The diet. should be nutritious and generous, more especially if the 
patient is feeble and ill nourished. Tonics, more particularly qui- 
nine and preparations of steel, should also be administered. 

We have now to consider, in the first place, whether we are 
enabled by any operative interference to prevent the occurrence of 
sympathetic ophthalmia) and, secondly, whether we can arrest its 
progress when it has once broken out. 

With regard to the first point, I may state that, as far as I am 
aware, no instance has been recorded in which sympathetic ophthal- 
mia ever attacked an eye after the injured eye had been removed, if 
at the time the other was still quite unafl'ected. This being so, there 
cannot be the slightest doubt as to the imperative advisability of 
the immediate removal of an eye which has been so greatly injured 
as to have quite lost its sight, or at all events to leave no hope of 
any restoration of a useful degree of vision. This is still more the 
case, if the injury has been of a kind which is prone to be followed 
by sympathetic ophthalmia. For we have no guarantee that we 
shall have time to check the sympathetic inflammation, if it has 
once broken out, even by a speedy removal of the injured eye. 
For although symptoms of sympathetic irritation not unfrequently 
usher in the inflammation, and the latter may be prevented by the 
excision of the injured eye at this premonitory stage, yet this is not 
always the case. The inflammation may occur without any pre- 
monitory symptoms, and advance so rapidly that in the course of a 
few days the integrity of the eye may be greatly, and perhaps per- 
manently, impaired. Thus, a case is narrated by Maats, in which 
within four days (and without any premonitory symptoms) an eye 
became so affected by sympathetic irido-cyclitis, that there was 
nearly a complete posterior synechia, and the sight had sunk to 
2 J^. In spite of the immediate removal of the injured eye, and of 
every endeavor to improve the condition of the other by iridectomy, 
and subsequently by a second iridectomy with removal of the lens, 
the eye became atrophied, and only retained perception of light. 
Such a case should warn us of the danger of procrastination in ex- 
cision of the blind injured eye, in the hope that there will always 
be time enough for this when symptoms of sympathetic irritation 
manifest themselves or during the earliest stage of sympathetic 
inflammation. For the former may never occur, and the latter 
may be so rapid in its development and course, that great and irre- 
mediable mischief may be done before we can enucleate the other 
eye. Moreover, there is another point which weighs heavily in the 
scale amongst persons whose livelihood depends upon their work, 
and that is the long time which is lost by them during the treat- 
ment of the injured eye. For it may remain painful and irritable 
for many months, and thus render the patient quite unfit to use the 
sound eye. It may be laid down as a fundamental rule, that as 
long as the injured eye remains painful to the touch it is always a 
source of danger, and may at any moment set up sympathetic oph- 



SYMPATHETIC OPHTHALMIA. 225 

thalmia. It should consequently be removed if its sight is lost, or 
greatly and irremediably impaired, this being particularly indi- 
cated if a foreign body remains within the eye. For thus only 
can we, insure the patient against the dangers of sympathetic in- 
flammation. The question as to whether the injured eye should be 
removed if it still retains some degree of vision is of course much 
more difficult and embarrassing. In deciding upon this point, we 
must be chiefly guided by the nature and extent of the injury. Thus, 
if it is a small incised wound of the cornea or sclerotic, and the 
iris, lens, and vitreous humor have escaped any severe injury, we 
may by careful and judicious treatment avoid the danger of sym- 
pathetic inflammation, and ultimately, perhaps, restore excellent 
vision. But if the wound is very extensive, and implicates the 
ciliary region and sclerotic, if the lens has been lost or is injured, a 
considerable amount of vitreous has escaped, or intra-ocular hemor- 
rhage has occurred, and if, consequently, the injuries are so great 
that but very little if any sight can possibly be saved, it is much 
better to remove the eye at once, even although some degree of 
vision may still exist. Still more imperative is such a course, if 
these extensive injuries are due to a foreign body which has become 
lodged in the eye and cannot be removed by operation, for although 
rare instances occur in which foreign bodies remain encapsuled and 
quiescent within the eye, such cases form, unfortunately, the great 
exception. I would especially urge the necessity for the operation 
if the patient resides at a distance from medical aid, so that a 
careful watch cannot be kept over the eye, and the first symptoms 
of sympathetic irritation or inflammation be at once detected. The 
question in all such cases is, whether it is not better to sustain a 
email loss than to run the risk of a very great danger. I, however, 
fully feel and admit the heavy responsibility which rests upon the 
surgeon who shall advise the removal of an eye which still possesses 
some sight, and when, as yet, no symptoms of sympathetic disease 
have appeared. We can in such cases only carefully and conscien- 
tiously weigh the different bearings of the case, and place them 
clearly and forcibly before the patient and his friends, and leave 
the decision in their hands. I have entered somewhat at length 
upon this part of the subject, because I feel it to be of great im- 
portance to all medical men, and one upon which they should hold 
strong and decided views. For we never know at what moment 
we may not be called upon to decide a question of this kind, and 
what reproaches we may not have to make ourselves if by our 
procrastination and indecision the second eye is lost from sympa- 
thetic ophthalmia. 

We must now pass on to the consideration of the question, as to 
whether we have any power of checking the progress of sympa- 
thetic inflammation if it has once broken out. If the sight of the 
injured eye is lost, it should be at once removed, for even although 
this proceeding may not always stop the progress' of the sympa- 
thetic disease, but only perhaps arrest it for a time, it will pro- 
bably at least exert a favorable influence upon its course, from the 
15 



226 DISEASES OF THE IRIS. 

removal of the primary source of irritation. But it will be different 
if some degree of sight still lingers in the injured eye, more espe- 
cially if the sympathetic inflammation has already produced ex- 
tensive injury, for then it must be borne in mind that in some 
similar cases the injured eye eventually proved of the most use to 
the patient, he having more sight in it than in the other. It ap- 
pears certain, from the experience of all authorities upon the subject, 
of sympathetic ophthalmia (amongst whom I would especially enu- 
merate Mackenzie, Bowman, Critchett, Graefe, Lawson, Donders, 
Pagenstecher) that any operative interference upon the second eye 
during the progress of the sympathetic inflammation is not only 
not beneficial, but even does positive harm, in increasing the in- 
flammatory proliferation of the exudation masses behind the iris, 
and thus hastening instead of arresting the progress of the disease. 
Von Graefe, however, mentions a case, in which the performance 
of an early iridectomy exerted a beneficial influence upon the course 
of the inflammation. He employed his narrow cataract knife, and 
made the incision very peripheral (just, in fact, as for the operation 
for cataract), and thus succeeded in seizing and excising a portion 
of iris. He, however, strongly advises that the iridectomy should 
be made as early as possible, as soon, in fact, as the ominous char- 
acter of the disease manifests itself. But, when the disease has 
become fully established, the pupil and posterior surface of the iris 
being tied down to the capsule of the lens by firm masses of exu- 
dation, and the tissue of the iris shows symptoms of disorganization, 
no operation should be performed. It is then far wiser to wait 
until the active inflammatory symptoms have subsided. Von Graefe 
thinks that we should wait until the tenderness of the ciliary region 
has diminished, the development of the large venous trunks in the 
disorganized iris become arrested or retrograding, the exudations 
in the pupil have changed their yellow color for a more bluish-gray 
tint, the intra-ocular tension (which is generally distinctly dimin- 
ished) shows no fluctuations,- and, finally, until at least three or 
four months have elapsed since the outbreak of the disease. In 
opposition to this, it might be urged that if the disease is thus 
allowed to run its course unchecked, the eye might become so atro- 
phied, and its functions so much Impaired, as to be beyond all hope 
of improvement. But, in such malignant cases, any operative in- 
terference only accelerates this result, and then, again, these are, 
according to Von Graefe, quite exceptional cases, for generally the 
atrophy of the eyeball becomes arrested at a certain point, not 
reaching perhaps a high degree, and the quantitative perception 
of light remains good. Under such circumstances, much advantage 
is gained by waiting as long as possible with the operation, because, 
as he states, " the vascularization and irritability of the exudation- 
masses diminish when the acme of the disease is passed, and besides, 
the extensive operative interferences which will have to be under- 
taken will be borne much better; whilst at an earlier period, 
hemorrhagic effusions from the delicate and newly developed 
vessels, and the proliferation of the neoplastic formations again 



SYMPATHETIC OPHTHALMIA. 227 

destroy the result of the operation. Moreover, the whole tendency 
of the diffusion of the traumatic irritation upon the choroidal tract 
diminishes with the prolonged existence of the disease ; and not 
unfrequently the tension of the eyeball becomes increased." 1 

The operation which should be performed in such a case is the 
removal of the lens, together with an extensive iridectomy and a 
dilaceration of the masses of exudation. This may be performed 
according to Yon Graefe's method, described at page 214, or to that 
practised by Bowman. 

The mode of performing the operation of excision of the eyeball 
is described in the chapter on " Diseases of the Orbit." 

I have already stated that the sympathetic irritation is evidently 
propagated by the ciliary nerves, and this fact has led Von Graefe 
to suggest the division of these nerves at the point where the 
ciliary region of the injured eye remains sensitive to the touch. 
Dr. Meyer, 2 of Paris, has performed this operation with marked 
success in several cases of sympathetic neurosis. After having 
raised and incised the conjunctival and subconjunctival tissue over 
the painful portion of the ciliary region, just as in the operation 
for strabismus, he introduces a squint hook underneath the tendon 
of the nearest rectus muscle, so that the eye may be well steadied. 
He then obliquely punctures the sclerotic at the painful point of 
the ciliary region with Von Graefe's narrow cataract knife, in such 
a manner that the wound lies parallel to the edge of the cornea. 
The vitreous humor is at once exposed by the incision. The hook 
being carefully removed the conjunctival wound is to be closed by 
a suture, the sclerotic incision healing in the course of a few days. 
[But little reaction follows the operation, and the only after-treat- 
ment required is rest, the hypodermic injection of morphia into the 
temporal region, and, when there is pain and restlessness, the appli- 
cation of a pressure bandage. 

This operation has been performed by Prof. Secondi, of Genoa, 
and by Mr. J. Z. Laurence, 3 of London, and with a satisfactory re- 
sult in each case.] 

1 "A. f. 0.," xii. 2, 165. 

2 " Annates d'Oculistique," Sept. 1867, p. 129. 

3 [" The Lancet," 1868, II. 633 ; also " Amer. Journ. of Med. Soi., Jan. 1869. 
p. 271.] 



Chapter IY. 

DISEASES OP THE CILIARY BODY AND 
SCLEROTIC. 



INFLAMMATION OF THE CILIARY BODY (CYOLITIS), 

ETC. 

The congestion and hyperemia of the ciliary body which are 
met with in cases of iritis accompanied by extensive posterior 
synechise, soon give rise to cyclitis, the inflammation but too fre- 
quently extending to the choroid. Again, the reverse may obtain, 
the inflammation may commence in the choroid, and extend thence 
to the ciliary body, and perhaps to the iris. But idiopathic cyclitis 
may also be met with, more especially after injuries to the ciliary 
region, such as contusions, incised or punctured wounds, or the 
lodgment in it of a foreign body. The presence of cyclitis is in 
such cases recognized by the fact that, together with the presence 
of photophobia, lachrymation, and very marked subconjunctival 
injection in the form of a bright zone of vessels round the cornea, 
there is acute, often indeed intense pain, on pressure of the ciliary 
region, great ciliary neuralgia, and perhaps hypopyon. We may 
distinguish two principal forms of cyclitis, the serous and the purulent. 

Serous cyclitis often supervenes in the course of serous iritis, more 
especially if the latter is severe in character, and has been negli- 

fently or injudiciously treated with astringent or caustic collyria. 
'he coexistence of serous cyclitis must be suspected, if, together 
with the symptoms of serous iritis, there is acute pain when the 
ciliary region is pressed with the end of a probe or a curette. This 
tenderness is very frequently situated at the upper or inner portion 
of the ciliary region, but where cyclitis is suspected it is always 
best to test the sensibility of the whole ciliary body. Also, if the 
tension of the eyeball is increased, accompanied by dilatation of 
the pupil and shallowness of the anterior chamber ; and if the 
vitreous becomes diffusely clouded, having also large fixed or float- 
ing opacities suspended in it. The veins of the iris are likewise 
often dilated and tortuous. Another very important symptom is 
the retraction of the ciliary margin of the iris, which is due to its 
being glued at this point to the ciliary body by an effusion of lymph. 
This retraction causes the anterior chamber to be abnormally deep, 
and the ligamentum pectinatum to spring forward like a ledge, 
giving the appearance (as Mooren aptly says) as if the iris were set 



INFLAMMATION OF THE CILIARY BODY. 229 

like a watch-glass in a rim. He has observed this retraction even 
in quite acute cases of cyclitis. 1 There is at the same time marked 
and rapid deterioration of the sight, which is in part dependent 
upon the opacity of the vitreous humor, and in part upon the in- 
crease of the eye tension, which causes compression of the retina. 
The accommodation and field of vision are also more or less im- 
paired. The supervention of cyclitis in cases of serous iritis is 
always to be regarded with apprehension, and the state of the sight, 
of the field of vision, and of the tension of the eye, should be 
watched with great anxiety, for if the symptoms do not yield to 
the usual remedies, but rather increase in severity, no time should 
be lost in performing iridectomy. Still graver is the danger in 
purulent cyclitis, which is characterized by the following symptoms : 
There is very marked subconjunctival injection, together with great 
ciliary neuralgia, photophobia, and lachrymation. The color of 
the iris is somewhat changed, and, if there is considerable iritis, it 
may be greatly altered. The veins of the iris are dilated. This, 
indeed, is a very pathognomonic symptom of cyclitis, and it is due 
to the following cause : On account of the inflammatory changes 
in the ciliary body and the retraction of the iris, the venous efflux 
from the iris is more or less impeded, and the blood does not readily 
flow off from the veinlets of the iris, which, therefore, become di- 
lated and engorged. The region of the ciliary body is very tender 
to the touch, sometimes the pain thus produced is so exquisitely 
acute that the patient shrinks back with apprehension. Pus makes 
its appearance in the anterior chamber, and sinks down to the 
bottom in the form of a more or less extensive hypopyon. It should 
be remembered that an hypopyon may be due to a purulent exu- 
dation from the ciliary body ; for at the rim of the anterior chamber 
the ciliary body is only separated from the latter by the delicate 
division of the membrane of Descemet, through which pus may 
easily exude into the anterior chamber, and then become precipi- 
tated in the form of hypopyon. If we can, therefore, exclude the 
origin of the latter from the cornea and iris; we may be certain, 
even apart from other symptoms, that it is due to cyclitis. The 
edge of the pupil is often adherent, its area blocked up with a 
dense plug of lymph, and a purulent exudation is but too frequently 
poured out behind the iris, and also perhaps into the vitreous 
humor. Purulent cyclitis is very apt to occur after injuries to the 
ciliary body, operations for cataract, and as sympathetic ophthal- 
mia; indeed, it is, as we have seen, the form under which the 
latter most frequently make its appearance. 

At the commencement, the constant application of hot poppy 
fomentations frequently affords very marked relief to the severe ciliary 
neuralgia, and sensitiveness of the ciliary region. Mooren strongly 
recommends the continuous use of warm poultices, which he applies 
for 4, 6, 10, or even 24 hours en suite if there is intense pain; but 
great care must be taken that they are kept at an equal temperature, 

1 Sympathisclie Gesichtsstorungen, p. 16. 



230 DISEASES OF THE CILIAEY BODY AND SCLEROTIC. 

and at once renewed when the patient complains of their heing cold. 
If the pain continues, and if there is great hypersemia and conges- 
tion of the subconjunctival vessels, as also of those of the iris, leeches 
should he applied, and when they have drawn very freely, a strong 
solution of atropine should be employed, in order to produce dilata- 
tion of the pupil as soon as possible. If there is much nocturnal 
pain, or the patient is restless, a subcutaneous injection of morphia 
is indicated. If the pain shows a marked periodic character, full 
doses of quinine should be given. "When a considerable exudation 
of lymph occurs into the anterior chamber, or into the vitreous 
humor, salivation should be induced as rapidly as possible by the 
inunction of the mercurial ointment. It must be confessed, how- 
ever, that in spite of every care, we are often quite unable to stay 
the progress of the disease, and prevent the loss of the eye from sup- 
purative irido-cyclitis, terminating in atrophy of the globe. As 
any accommodative effort of the healthy eye increases the pain in 
the affected one, it is best to forbid all use of the former, or even to 
cover it with a bandage, so as to keep it quite at rest. 

An extensive iridectomy, if performed at an early stage of the 
disease, often exerts a very beneficial influence upon the course of 
the latter. At a later period it is but too frequently followed by a 
recurrence of severe inflammation, with a fresh exudation of pus, 
which completely blocks up the artificial pupil. Mooren 1 strongly 
objects to any operative interference (especially an iridectomy), 
for he considers its .action not only of doubtful benefit, but even in 
some cases very dangerous. Only in rare instances does he perform 
paracentesis. 

Injuries implicating the ciliary region are not only dangerous on 
account of the inflammatory complications to which they may give 
rise in the injured eye, but also on account of the risk of sympa- 
thetic ophthalmia, which they are very prone to excite. Simple 
incised wounds of the sclerotic at or near the edge of the cornea will 
often rapidly unite, on the insertion of a fine suture, if they are not 
extensive in size, and have not penetrated too deeply, and thus caused 
severe injury to the ciliary body, lens, etc. Such wounds may be 
produced by fragments of glass or steel, or by a clean cut from a 
small sharp instrument. In the former case, a careful examination 
should always be made as to the presence of the foreign body, which 
may either have fallen out after having wounded the sclerotic, have 
entered the eyeball, or be lying in the lips of the wound, whence 
it may be readily extracted. A bead of vitreous is seen protruding 
between the lips of the little wound, and this constant oozing 
greatly diminishes the intra-ocular tension, the eye being gene- 
rally extremely soft. But whilst the tension in the vitreous humor 
is much diminished, that in the anterior chamber may be aug- 
mented, the iris being cupped backwards and the depth of the 
anterior chamber much increased, and being occupied by yellowish 

1 "Op. cit."p. 31. 



DISEASES OF THE SCLEROTIC. 231 

serum. This causes a peculiar and markedly greenish discoloration 
of the iris, more especially if the latter is normally of a blue or 
bluish-gray tint. In such cases, by far the best treatment consists 
in bringing the lips of the little scleral wound together with a line 
suture. This is best and most safely done by attaching a curved 
needle to each end of a very fine silk thread, and passing one needle 
through the one edge of the wound from within outwards, and the 
other needle through the opposite edge also from within outwards. 
In this way we shall avoid all danger of injuring the ciliary body 
or lens from a sudden jerk of the point of the needle deeply into the 
eye. The suture generally produces little or no irritation, and may 
be left for eight or ten days, until the wound is firmly united. As 
soon as the oozing of the vitreous is arrested, the intra-ocular ten- 
sion increases, and in the course of a day or two it generally reaches 
the normal standard. If the depth of the anterior chamber is much 
increased by the accumulation of serum, an iridectomy should be 
made to re-establish the communication between the anterior and 
posterior chambers. 

A description of the tumors met with in the ciliary region will 
be found in the article upon " Tumors of the Choroid." 



DISEASES OF THE SCLEROTIC. 
1.— EPISCLERITIS. 

Though not a dangerous affection, episcleritis often proves ex- 
tremely troublesome on account of the protracted and obstinate 
course which it runs, and also on account of the tendency to fre- 
quent recurrence which it often manifests. It is distinguished by 
the appearance of a small dusky-red, or reddish-yellow elevation 
on the sclerotic, in close proximity to the insertion of one of the 
recti muscles, and at a short distance from the edge of the cornea. 
It occurs most frequently at the temporal portion of the sclerotic, 
near the insertion of the external rectus muscle. The appearance 
of the little nodule is generally preceded and accompanied by more 
or less conjunctival and subconjunctival redness, more especially of 
that segment of the eyeball upon which the elevation is situated, 
to which, indeed, the vascularity is often confined. The subcon- 
junctival tissue is at this point markedly thickened and swollen, 
and of a peculiar rusty, dark, purplish hue, its bloodvessels (as 
well, perhaps, as those of the conjunctiva) being here somewhat 
dilated, tortuous, and of a dusky tint. Frequently the conjunctiva 
is hardly at all affected, the vascularity and swelling being con- 
fined to the subconjunctival tissue and the superficial layers of the 
sclerotic. There is sometimes considerable photophobia, lachry- 
mation, and a certain degree of ciliary neuralgia, but in many 
cases these symptoms are almost entirely absent, and the patient 
experiences only slight discomfort, or a feeling of dull, heavy pain 



232 DISEASES OF THE CILIAEY BODY AND SCLEROTIC. 

in and around the eye. The affected point of the sclerotic may 
also be more or less sensitive to the touch. At the outset, the 
affection might be mistaken for phlyctenular or pustular ophthal- 
mia, but the little nodule soon increases in size, and assumes a 
dusky, reddish-brown appearance, having a broad base, and show- 
ing no tendency to ulcerate or suppurate. Gradually it becomes 
more pale, diminishes in size, and slowly disappears, after it has 
existed perhaps for many months. Or it may recur again and 
again, either at the same spot, or at some other point of the eye- 
ball, so that the disease may travel round the cornea from point to 
point. 

The disease is not only very protracted and obstinate in its 
course, but also very little influenced either by general or local 
treatment. It occurs most frequently in females of an adult age, 
and does not appear to be due to any appreciable cause, except that 
it is perhaps more often met with in persons of a rheumatic or 
gouty tendency than in others. In some cases it would also appear 
to be due to a syphilitic taint, and is then apt to prove extremely 
obstinate, except it is treated by anti- syphilitic remedies. The 
cornea sometimes becomes implicated, more especially the part 
nearest the elevation, the superficial portions of the cornea becom- 
ing cloudy, and this opacity assuming somewhat the appearance 
of a partial arcus senilis. If there is much ciliary irritation and 
pain, atropine drops should be employed, and warm poppy fomen- 
tations be applied to the eye. The insufflation of calomel or the 
use of the red-precipitate ointment have proved of little benefit in 
my hands ; indeed, I think them contra-indicated if there is any 
ciliary irritation, still more so is this the case with caustic collyria. 
I have, however, in some cases found marked and striking benefit 
from the use of a collyrium of chloride of zinc. I employ at first 
a very weak solution (gr. §■ to 3j of water), and if this is well borne 
and does not augment the redness or produce much irritation, I 
increase the strength to gr. j-ij to gj. The patient should be 
placed upon a generous diet, and tonics should be freely admin- 
istered. Where there is a distinct gouty or rheumatic tendency, 
preparations of guaiacum, or colchicum together with the tincture 
of aconite, should be given. If there are evidences of syphilis, the 
iodide of potassium should be prescribed, and perhaps even mercu- 
rial inunction. 



2.— ANTERIOR SCLEROTIC STAPHYLOMA. 

Staphylomatous bulging of the sclerotic may be chiefly or entirely 
confined to one part of the anterior portion of the sclerotic, or it 
may involve, more or less, the whole of the eyeball. The partial 
anterior staphyloma is generally situated near the ciliary region, or 
further back, near the equator of the eye. It may occur at any 
point from the edge of the cornea to the equatorial region of the 
eyeball, and frequently shows itself between the insertion of two of 



ANTERIOR SCLEROTIC STAPHYLOMA. 233 

the recti muscles, as there is less resistance offered at such a point 
to the protrusion of the sclerotic. 

In the great majority of cases, staphyloma of the sclerotic is due 
to irido-choroiditis, accompanied by an increase in the intra-ocular 
tension, which leads to distension and' bulging of the sclerotic at 
one or more points, the resistance of the sclerotic having moreover 
been perhaps also weakened by an inflammatory thinning of its 
structure. The prominence of the inflammatory symptoms varies 
very greatly, according to the rapidity and acuteness with which 
the staphyloma is formed. If the course of the disease is very 
acute, we find that there are marked S3 T mptoms of irido-choroiditis. 
There is conjunctival and subconjunctival injection, accompanied 
perhaps by a certain degree of chemosis, more especially over and 
around that part of the sclerotic which is beginning to bulge. The 
ciliary neuralgia is often very severe, and the ciliary region acutely 
sensitive to the touch. The edge of the cornea may be somewhat 
opaque, the aqueous humor hazy, the iris discolored and inflamed, 
and its pupillary edge tied down by exudations of lymph. 

If the pupil is sufficiently clear to admit of an ophthalmoscopic 
examination, the vitreous humor is often found diffusely clouded, 
with large, dark shreds floating about in it. The tension of the 
eye is generally considerably increased, and the sight and field of 
vision greatly impaired. The increase in the eye-tension is not, 
however, absolutely necessary to the production of a staphyloma. 
For on account of an inflammatory thinning of a certain portion of 
the sclerotic, the latter may not be sufficiently firm and strong at 
this point to resist the presence of even a normal degree of intra- 
ocular tension, and consequently yields before it. In such a case, 
there would of course be no augmentation of the eye-tension, no 
hardness of the globe. Such cases are, however, rare in comparison 
to the others, in which the increase of the tension is the' chief cause 
of the protrusion. Besides the severe pain, the patient often com- 
plains of bright flashes of light (photopsies). Soon there is noticed 
at one point of the sclerotic a slight prominence or bulging, the 
outline of which may be circumscribed and clearly denned, or be 
irregular and pass gradually and insensibly over into the healthy 
sclerotic. As the bulge increases, the sclerotic becomes more and 
more thinned (partly perhaps from inflammation and partly from 
distension) and discolored, assuming at this point a dusky, dirty 
bluish-gray hue, which is due to the shining through of the choroid. 
Thus the staphyloma may attain a considerable size even in the 
course of a few weeks. [Fig. 86.] Together with the increase 
in the size of the staphyloma, the proximate portion of the ciliary 
region, and even of the cornea, may become involved in it, and be 
considerably changed in curvature, the corresponding plane of the 
iris and the zonula of Zinn being stretched, and the attachment of 
the lens consequently relaxed and loosened. 

As a rule, however, the progress of the staphyloma is very slow 
and gradual. After a more or less acute and severe inflammation 
of the iris and choroid has existed for some length of time, and its 



234 DISEASES OF THE CILIARY BODY AND SCLEROTIC. 



progress has been perhaps apparently arrested, it is noticed that the 
curvature of one portion of the sclerotic is somewhat altered and 
more prominent, and its surface traversed by dark, dilated vessels. 
Gradually and slowly the protrusion increases, the sclerotic becomes 



[Fig. 86. 




Fig. 87. 



After Miller. 




After Miller.] 



more thinned, and exchanges its bright lustrous white color for a 
dusky bluish tint. Sometimes the staphylomatous bulging is tra- 
versed by tendinous glistening tuberculse, forming a kind of frame- 
work, through the insterstices of which the darker portions bulge 
out, giving to the whole a faint likeness to a mulberry. [Fig. 87.] 
The staphyloma may now remain stationary for a time, and the 
inflammatory symptoms disappear. Then an inflammatory exacer- 
bation supervenes, the eye becomes painful, irritable, flushed, and 
an increase in the size of the staphyloma is noticed. But these 
symptoms again disappear, and the progress of the disease is tem- 
porarily arrested. Such exacerbations may be of frequent occur- 
rence, and lead, finally, to a considerable and very prominent staphy- 
loma. Sometimes the staphylomatous 
I [F'g- 88. bulgings are not chiefly confined to one 

portion of the sclerotic, but occupy the 
whole of the ciliary region around the 
cornea, and then the disease is termed 
"annular staphyloma." [Fig. 88.] 

The distension and bulging is not 
limited to the sclerotic, but extends to 

t; the choroid, which is generally adherent 

to the former, and consequently stretched 
w^^^^, \ and bulged with it, undergoing in time 
perhaps almost complete atrophy. The 
retina may either be adherent to the 
choroid, and therefore also stretched 
and altered in structure, or it may be 
separated from it at this point, and pass 
straight across the base of the staphy- 
lomatous bulge, the cavity of the latter being occupied by serous 
fluid. The vitreous humor is also more or less clouded and fluid. 




ANTERIOR SCLEROTIC STAPHYLOMA. 235 

Sometimes it is however quite transparent, and we can then dis- 
tinctly see (if the other refractive media are clear) the details 
of the fundus, and perhaps detect a deep excavation of the optic 
nerve. Generally, however, we are unable to see the fundus on 
account of exudations in the pupil, or the opacity of the lens and 
vitreous humor. 

In complete sclerotic staphyloma, the anterior portion of the scle- 
rotic and the cornea are greatly altered in curvature, being either 
distended into a conical, or sub-ovoid protrusion. The iris and 
zonula of Zinn are also much distended. The plane of the iris is 
greatly increased in size, and its surface is of a dirty slate tint, 
which is partly owing to inflammatory changes, and partly to the 
stretching and atrophy of its fibrillse. It is, moreover, often tre- 
mulous, on account of the partial or complete dislocation of the 
lens, or on account of the latter being separated from its posterior 
surface by a considerable amount of fluid. From the distension 
and stretching of the zonula of Zinn, the attachments of the lens 
are relaxed and weakened, and the latter may be partially or com- 
pletely dislocated into the vitreous humor. The depth and size of 
the anterior chamber are often greatly increased. Indeed the whole 
eye is much enlarged, and on this account as well as the protrusion 
of the eye from the orbit, this condition is often termed " buph- 
thalmos." The sclerotic is traversed by dilated tortuous vessels, 
and is of a dusky, dark-blue tint, which is either diffuse and uni- 
form in character, or chiefly confined to certain points, giving to 
the whole a dark, patchy appearance. The pupil is often occupied 
by lymph, the capsule of the lens opaque, and covered by masses of 
exudation, the lens itself being also frequently cataractous. If the 
staphyloma has formed after an extensive perforation of the cornea, 
there will be no anterior chamber, the iris and capsule of the 
lens are intimately connected with and adherent to the corneal 
cicatrix, the lens is cataractous, perhaps shrivelled and chalky, or 
altogether absent, having escaped through the corneal perforation. 

Both the partial and complete styphyloma may after a time 
become arrested, the inflammatory exacerbations becoming less and 
less frequent, and finally ceasing. In other cases, severe suppurative 
irido-choroiditis supervenes, and gradually leads to atrophy of the 
eye. Or again, the bulging portion in a partial staphyloma may 
give way, either spontaneously or in consequence of a blow upon 
the eye, or a sudden and severe strain or exertion. A great portion 
of the contents of the eyeball escapes, this being often accompanied 
by profuse intra-ocular hemorrhage ; severe inflammation super- 
venes, and the globe shrinks and atrophies. 

With regard to the treatment, I need only say that at the very 
outset of the disease, when the symptoms are only those of irido- 
choroiditis, the usual remedies — atropine, leeches, paracentesis, etc. 
—should be employed, but when the tension of the eye is markedly 
increased, and if the sclerotic shows at one point a tendency to 
bulge, these remedies no longer suffice, and a large iridectomy 
should be made at once. If this should not check the inflammation 



236 DISEASES OF THE CILIAEY BODY AND SCLEROTIC. 

and the bulging of the sclerotic, repeated paracentesis may be tried, 
or a second iridectomy may be made opposite to the first, so as to 
divide the iris into two separate halves. But if the staphyloma is 
considerable and has existed for some time, the iridectomy no 
longer suffices to cause it to shrink, and we may then have to 
abscise it. This should be done with a cataract knife, as in the 
case of staphyloma of the cornea (page 157). After the operation 
a firm compress bandage is to be applied. In cases of partial sta- 
phyloma, more especially if the base is small, I should prefer 
Borelli's operation (page 161) to abscision. In those cases in which 
the sight is greatly and hopelessly lost, and the eye is a source of 
constant irritation and discomfort, abscision by Critchett's method 
should be performed. But if the disease reaches far back, or in- 
volves the whole eyeball, it will be much wiser to excise the eye, 
for by abscising the anterior part, a portion of the diseased struc- 
tures will be left behind, and the stump be prone to inflammatory 
complications, and thus'prevent perhaps the possibility of wearing 
an artificial eye with comfort, and even endanger the safety of the 
other eye. 



3.— WOUNDS AND INJURIES OF -THE SCLEROTIC. 

Incised wounds of the sclerotic chiefly prove dangerous in so far 
that, if they are extensive, a considerable portion of the contents 
of the eyeball escapes, which is perhaps followed by profuse intra- 
ocular hemorrhage, suppurative choroiditis, and finally, atrophy of 
the eyeball. Or again, if the wound is smaller, its cicatrization 
may, by involving a portion of the retina, lead to a detachment of 
the latter, which, though limited at first, may gradually extend 
and threaten the safety of the eye. Again, the instrument pro- 
ducing the injury may wound the lens and cause traumatic cataract, 
accompanied perhaps by severe inflammatory complications leading 
to the destruction of the sight. Still greater is the danger if the 
point of the instrument is broken oft" and lodged in the interior of 
the eye, the same being the case, if foreign bodies have perforated 
the sclerotic and entered the globe. If the wound is situated at 
the anterior portion of the sclerotic near the cornea, the iris gene- 
rally protrudes, and the lens may be dislocated under the conjunc- 
tiva; this is especially the case after severe blows from blunt 
instruments, producing a rupture of the sclerotic. Indeed, ruptures 
of the sclerotic are generally far more dangerous than incised 
wounds, on account of the great force of the blow which was 
necessary to cause the sclerotic to give way. If the incised wound 
is not considerable in size, its edges should be carefully brought 
together by a fine suture or two. Any portion of protruding iris 
or vitreous humor being abscised, cold compresses should then be 
applied to allay the inflammatory reaction. In small punctured 
wounds a little bead of vitreous may protrude through the aperture, 
and if the application of a firm compress does not accelerate union, 



WOUNDS AND INJURIES OF THE SCLEROTIC. 237 

this object may be obtained by lightly touching the wound with a 
crayon of nitrate of silver and potash every second or third day. 
"When the wound is very extensive and a large portion of the 
contents of the globe has escaped, and there is no hope of restoring 
any sight, it is better to excise the eyeball at once, more especially 
if it is to the patient a matter of great moment (as amongst the 
poorer classes) to be cured as soon as possible, and to be free from 
further inflammatory attacks. 

A portion of the sclerotic may slough after injuries from burns, 
hot metal, etc. The injured part becomes covered with a whitish- 
gray eschar, which is thrown off together with portions of the 
sclerotic, until the vitreous humor becomes visible. The injury 
may be accompanied by inflammation of the cornea and iris, and 
opacity of the lens. 



Chapter V. 



DISEASES OF THE CRYSTALLINE LENS. 



1.— CATARACT. 

By the general term " cataract" is understood an opacity situated 
in the crystalline lens : to such only should it be applied. When 
the opacity is in the capsule, it is termed " capsular cataract ;" 
whereas, when both the capsule and lens are involved, it is desig- 
nated "capsulo-lenticular cataract." The term " spurious cataract" 
of old authors, which was the name given to deposits of lymph in 
the pupil, should be altogether abolished. 

It must be frankly admitted that the etiology of cataract is still 
shrouded in much obscurity and doubt. It appears most probable 
that the principal causes of the loss of transparency of the lens are 
to be sought in an impairment of its nutrition, due to some morbid 
alteration in the vitreous humor, and in inflammatory changes 
within the lens itself. The defect in the nutrition may be due to 
certain alterations in the condition of the blood, to senile involu- 
tion, or to inflammatory lesions of the neighboring tunics {e.g., iri- 
do-choroiditis, sclerotico-choroiditis posterior, retinitis pigmentosa, 
etc.). According to Mooren 1 the formation of cataract is always a 
secondary, never a primary phenomenon ; its origin being always 
due to certain inflammatory or atrophic changes in some portion of 
the uveal tract. Simple affections of the optic nerve or retina, 
\ \ Jto-i^ich are unaccompanied by any changes in the vitreous, do not 
. |jV|J6xert any influence on the development of cataract. Cataract is 

jylV*^ » j not unfrequeutly met with in those conditions of the blood in 
» JJ^M which its watery constituents are very deficient, so that it assumes 
*P V \fgreat density (as, for instance, in diabetes). This gives rise to an 

exosmosis of the watery constituents of the lens, a loss of transpa- 
rency in its fibres, and a deposit of calcareous and other salts. In 
diabetes, the cataract does not generally appear until a late stage of 
the disease, when the patient is greatly emaciated and enfeebled, 
and his health much broken. I have, however, met with some 
cases in which the opacity of the lens appeared whilst the general 
health was still good. The diabetic cataract is mostly met with 
about or before middle age, and does not present any peculiar or 
characteristic symptoms. It generally affects both eyes, and is 

1 " Ophthalmiatrische Beobachtungen," p. 208. 



CATARACT. 239 

mostly of a softish consistence, and rapid in its formation. In 
elderly persons, however, it will be more firm, and contain a more 
or less large hard nucleus. The perception of light, and the con- 
dition of the field of vision should always be very carefully ex- 
amined in such cases, as affections of the retina and optic nerve not 
unfrequently occur in the course of diabetes, and may, therefore, 
coexist with the cataract, and thus render the prognosis of the ope- 
ration unfavorable. Another fact which should be remembered in 
operating for diabetic cataract is, that the iris is often very suscep- 
tible of irritation, so that iritis is exceptionally easily set up. The 
amblyopia which is sometimes met with in persons affected with 
diabetes may, however, be simply due to paralysis of the accom- 
modation. 

The presence of secale cornutum in the system may produce I 
cataract. Thus, Dr. Ignaz Meyer 1 has shown that the consumption 
of bread containing ergot of rye may give rise to it. The ergotism/ 
has lasted in some of these cases for two or three months, the/, 
principal symptoms being the fits. The development of the cataract 
was very slow, and always occurred in both eyes. The mode in 
which the ergotism gives rise to cataract is still very uncertain, 
but it is probably due to some impairment of the nutrition of the 
lens. Wecker thinks that this mal-nutrition may, perhaps, be 
owing to a diminution in the blood supply to the anterior portion 
of the uveal tract, on account of the prolonged spasmodic contrac- 
tion of the ciliary muscle. Rothmund 2 has observed a rapid de- 
velopment of cataract in children who were affected with a very 
peculiar disease of the skin, which somewhat resembled ichthyosis. 

Cataract is, as a rule, a disease of old age, and the loss of trans- 
parency of the lens is probably chiefly due to its deficient nutrition, 
dependent upon an inefficient blood supply, and consequent dimi- 
nution of the watery constituents of the crystalline. We must not, 
however, mistake for this condition, the small punctated opacities 
which are due to senile fatty degeneration of ^he fibrillse of the 
lens, and which sometimes appear in old persons in the form of a 
fringe of small, yellowish, gray dots, situated quite at the periphery 
of the lens, where they may remain stationary for a very long 
period. It is an interesting fact that IwanofP has often found 
oedema of the retina in the eyes of old persons affected with cata- 
ract, and it is a question, as he points out, in how far this morbid 
process in the retina may have been the cause of the cataract, by 
producing some changes in the vitreous humor. 

Inflammations of the inner tunics of the eye, more especially of 
the iris, choroid, and vitreous humor, may give rise to cataract, 
not only by an impairment of the nutrition of the lens, but also by 
the inflammatory changes implicating the intra-capsular cells, and 
even the lens itself. Again, the cataract may be due to the 
presence of extensive deposits of lymph upon the capsule, which 

1 " A. f. O.," viii. 2, 120. 2 Ibid. xiv. 1, 159. 

3 "A. f. O.," xv. 2, 90. 



240 DISEASES OF THE CRYSTALLINE LENS. 

prevent the osmotic interchange of material between the lens and 
aqueous humor. If these exudations cover the greater portion of 
the anterior capsule, the opacity of the lens generally soon becomes 
complete, whereas, if the exudation is confined to the area of the 
pupil, the cataract is often only partial. In the former case, the 
watery constituents of the lens soon become absorbed, the lens be- 
comes diminished in size and shrivelled up, and may in time be 
almost entirely absorbed, there being only an opaque, white, chalky 
disk left behind. 

Cataract is very frequently due to some injury to the lens, but 
this form will be considered more at length under the head of 
" Traumatic Cataract." 

Considerable difficulty is experienced in attempting to classify 
the principal forms of cataract in such a manner that their dis- 
tinctive features shall be easily recognized and remembered. Mot 
only are the minor varieties numerous, but some of them do not 
present any marked characteristics, so that their description often 
proves somewhat confusing and unintelligible to the novice. 

I think it most practical to divide lenticular cataracts into two 
principal classes : 1. The cortical, or soft cataract ; 2. The nuclear, 
or hard cataract. The former is the most frequent kind of con- 
genital cataract, and is' met with in various forms up to the age of 
30 or 35, and is chiefly characterized by the fact that, although 
the whole lens may be involved in the process, there is no hard 
nucleus. The 'nuclear cataract occurs generally after the age of 35 
or 40, and is distinguished by the presence of a more or less large, 
yellow, hard, nucleus. I am well aware that so general a division 
is open to the objection that exceptional cases are not unfrequently 
met with, so that all varieties cannot be embraced in it. Yet in a 
practical point of view I believe it to be the best, as it enables us 
to lay down broad rules as to the modes of operation to be selected. 
For instance, the cortical cataract may be operated upon by divi- 
sion with the needle, by suction, or by linear extraction ; whereas, 
the nuclear cataract, on account of the presence of a hard nucleus, 
demands extraction either through a corneal or scleral flap, or by 
the assistance of some form of traction instrument. 

But there is one form of soft cataract which requires a special 
description, as, on account of its peculiar structure, it may often 
be best treated by an operation which does not interfere with the 
lens itself. I mean the lamellar or zonular cataract. Cataracts 
produced by injuries to the lens, and opacities in the capsule, will 
be considered under the heads of " Traumatic Cataract," and " Cap- 
sular Cataract." 

Formerly, much attention was paid to the symptoms which dis- 
tinguished cataract from glaucoma and amaurosis. But since the 
discovery of the ophthalmoscope, these diseases could not be mistaken 
for cataract, except through the grossest ignorance or carelessness. 

A fully formed, mature cataract may be at once recognized even 
with the naked eye. The pupil is no longer dark and clear, but is 




CATARACT. 241 

occupied by a whitish opalescent body, which, lies close behind it. 
[Fig. 89.] It is different, however, when the affection is 
incipient and but slightly advanced, more especially P^S- 89 -l 
when the opacity commences at the edge of the lens, for it 
may then be easily overlooked except the eye is carefully 
examined with the ophthalmoscope and the oblique illu- 
mination. If elderly persons complain somewhat of dim- 
ness of sight, the condition of the lens should always be examined, 
even although they may apparently be only suffering from presbyopia 
and are able to read the smallest print with suitable convex glasses ; 
for amongst the aged, cataract is most common, and often com- 
mences at the very edge of the lens in the form of small spicular 
opacities, which might easily escape detection. Wherever incipient 
cataract is suspected, the pupil should be dilated by a weak solu- 
tion of atropine, and the lens examined with the ophthalmoscope 
and the oblique illumination. If there is any objection to dilating 
the pupil, a very fair view may, however, be obtained even of the 
margin of the lens, by directing the patient to turn his eye to one 
side, and then looking very slantingly behind the iris. 

Care must, however, be taken not to mistake the physiological 
changes which occur in the lens in old age, for commencing cata- 
ract. These changes consist in a thickening and consolidation of 
the lens substance, especially of the nucleus, which assumes a yel- 
low tint. If this physiological cloudiness is very marked, it might 
easily be mistaken for incipient cataract. The chief distinctive 
features are, that in the former case the sight is perfect (any exist- 
ing presbyopia being corrected by suitable glasses), the opacity re- 
mains absolutely or almost entirely stationary for a very long period, 
and the cloudiness is not observable with the ophthalmoscope, al- 
though perhaps very evident with the oblique illumination. 

The catoptric test, which was formerly much employed in the 
diagnosis of cataract, has fallen into complete disuse since the dis- 
covery of the ophthalmoscope, and the introduction of the oblique 
illumination. The catoptrical examination depended upon the 
three images which may be observed in a healthy eye when a lighted 
taper is moved before it. Two of these images are erect, the third 
is inverted. The first is an erect image of the candle, and is pro- 
duced by reflection from the surface of the cornea ; the second is 
also erect, and is produced by reflection from the anterior sui'face 
of the lens ; the third is inverted, and is due to reflection from the 
concave posterior surface of the lens. The first two images move 
in the same direction as the candle, the third in the opposite direc- 
tion. If the lens becomes opaque, of course the image from the 
posterior surface is lost, and that from the anterior surface also 
soon becomes indistinct. 

With the oblique illumination, opacities in the lens will appear 
of a light gray, or whitish color. The slighter forms are best seen 
by only a moderate amount of light. 

In employing the ophthalmoscope for the diagnosis of cataract, 
the mirror alone is to be used (without any lens in front). To gain 
16 



\ 

242 DISEASES OF THE CRYSTALLINE LENS. 

a larger image, a convex lens may be placed behind the mirror. 
The illumination is to be weak. Incipient cortical cataract, com- 
posed of centripetal stripes, will appear in the form of well-defined 
dark streaks upon a red background. Punctiform opacities also 
appear as dark spots, but are often not so observable as with the 
oblique illumination. 

I will now briefly describe the characteristic appearances pre- 
sented by the different forms of cataract. 

I. Lamellar or zonular cataract {Schichtstaar) is generally con- 
genital or developed in early infancy. Arlt originally called atten- 
tion to the fact that it often occurs in children who have suffered 
from convulsions, but the connection between the two has not yet 
received a satisfactory explanation ; for it is difficult to understand 
why only certain perinuclear layers of the lens fibres should be 
affected by the mal-nutrition or succussion consequent upon the 
violent muscular spasms during the convulsions. 

As lamellar cataract does not materially impair the sight, it often 
escapes detection until much later in life. Its appearance is very 
characteristic, and its diagnosis easy. On dilating the pupil with 
atropine, we observe an opacity of the lens measuring from two to. 
three and a half lines in diameter. It is quite uniform from the 
periphery to the centre, and is sharply defined against the transpa- 
rent margin of the lens. The cataract consists, in short, of a layer 
of opaque lens substance lying between the nucleus and a transpa- 
rent portion of the cortical substance. Hence it has been designated 
" Schichtstaar," or lamellar cataract. The nucleus of the lens is 
transparent, which is proved by the uniform character of the opacity, 
which is not more dense in the centre than at the periphery, and 
by the relatively fair sight which such patients enjoy even when 
the pupil is not dilated. Moreover, with the ophthalmoscope, a 
reddish-brown reflex shines through the central portion of the lens. 

With the oblique illumination, the opacity appears of a uniform 

light gray color, sharply defined, and surrouuded by a more or less 
broad margin of transparent cortical substance. It will now also 
be seen that there is a clear portion of cortical substance between 
the opacity and the anterior capsule. In the centre of the opacity 
may often be remarked one or more small white spots. With the 
ophthalmoscope, the opacity has the appearance of a well-defined 
dark disk, the centre of which affords a reddish-brown reflex. If 
the margin of the cortical substance be clear, the details of the fun- 
dus will be visible through it. If there are opacities in it, they wil ft— P 
appear as fine dark stripes or specks upon a red background. 
Some of the varieties of lamellar cataract are very pretty. For in- 
stance, I have seen cases in which little stripes ran from the opacity 
into the cortex, their extremities being studded with small pearl- 
like opacities. Lamellar cataract is either stationary or very slowly 
progressive. It is, therefore, of consequence, before deciding upon 
an operation, to determine whether the cataract be progressive or 
not. In deciding this, we must be chiefly guided by the condition 
of the marginal cortical substance. If the latter is perfectly clear 



CATARACT. 243 

and transparent, the cataract is stationary ; if it is diffusely clouded, 
or presents puuctiform or striped opacities, it is progressive. Von 
Graefe thinks that its progress is most rapid when the stripes are 
broad, and the interjacent lenticular substance is somewhat opaque 
and studded with coarse specks. If the opacities consist only of 
very fine dots, or a few delicate narrow stripes, the progress is very 
slow. 

According to Yon Graefe, lamellar cataract may also be formed 
later in life in dislocated lenses, and after iritis. 

Vision may be relatively good if the opacity is not dense ; for 
instance large print may be read. But the sight is always im- 
proved by dilatation of the pupil with atropine, for this permits 
the rays from the object to pass through the clear marginal portion 
of the lens. I have seen cases in which the difference in the sight 
before and after dilatation of the pupil, has been most marked ; so 
that persons who, prior to it, could with difficulty decipher large 
letters, were afterwards able to read the smallest print. The ac- 
companying diagrams (Figs. 90 and 91) will explain this. Fig. 90 

Fig. 90. Fig. 91. 





(a) the undilated pupil occupied by the opacity (b), which extends 
beneath the iris as far as the dotted line (c), where the transparent 
margin (d) commences. As the latter is completely covered by 
the iris, the rays can only pass through the central opaque portion ; 
hence the indistinctness of sight. But on dilatation of the pupil 
(Fig. 91) the transparent margin (d) is exposed, and the rays can 
now pass through it to the retina. The solution of atropine to be 
used for dilating the pupil should be extremely weak (gr. j to 
eight or twelve ounces of water), so that we may obtain complete 
dilatation of the pupil without any paralysis of the accommodation. 
If this point is not attended to, we may easily be misled by the 
fact of the patient's complaining that after the dilatation the sight 
is dim and misty, which may be due simply to the fact that the 
accommodation is paralyzed by the atropine, which was too strong. 

Persons suffering from lamellar cataract are often supposed to be 
short-sighted, as they hold small objects (a book, for instance) 
very close to the eye, in order to gain larger retinal images. In 
time, however, this constant accommodation for very near objects 
may really give rise to myopia of even a considerable degree. 

In practice, it is important to remember two facts with regard 
to lamellar cataract — 1. That the opacity is surrounded by a more 
or less clear margin of cortical substance, which, if it be sufficiently 
wide and transparent, may admit of excellent sight when the pupil 
is dilated. 2. That the greater portion of the lens is transparent 



244 DISEASES OF THE CKYSTALLINE LENS. 

and in a normal condition, and will, therefore, swell up far more 
than a cataractous lens, after laceration of the capsule and the 
admission of the aqueous humor, as, for instance, in a needle ope- 
ration. 

II. Cortical Cataract. — The opacity generally commences at the 
margin. Small, grayish-white stripes are observed running to- 
wards the centre of the lens. At the very commencement, the 
interjacent lens substance is either perfectly transparent, or but 
sparsely studded with little opaque dots. Soon, however, the 
cloudiness becomes more general and diffuse, until the whole lens 
is involved. Sometimes the stripes may be observed both on the 
anterior and posterior cortical substance, the lens between them 
being transparent. The difference in their position may be easily 
recognized with the oblique illumination. The anterior stripes are 
close behind the pupil, whereas the others are far back in the eye, 
and appear concave, the concavity being turned towards the ob- 
server. 

On examining an incipient cortical cataract with the ophthal- 
moscope, we notice dark, well-defined stripes intersecting the red 
background, and radiating from the margin of the lens to the 
centre. Between them, at the very edge of the lens, there is often 
a fringe of short, stunted stripes. Punctiform opacities, which 
with the oblique illumination appeared of a gray color, now look 
like little dark dots strewn about on and between the stripes. 

In rare instances the opacity, instead of being striped, consists 
of innumerable little dots with clear portions of lens substance 
between them. "With the naked eye it looks like a diffuse uniform 
opacity. 

The following symptoms are characteristic of a fully formed, 
mature cortical cataract: The opacity is of a gray or bluish-white 
color, which increases somewhat in density towards the centre. 
On account of this white tint, the movements of the pupil appear 
peculiarly marked and distinct. If the volume of the lens be in- 
creased through the imbibition of fluid, the iris may be slightly 
arched forward, and the pupil somewhat dilated and sluggish. The 
stripes are broad, white, and often very opalescent, like mother of 
pearl. There is no admixture of yellow in the color of the opacity, 
which proves at once that the nucleus is not hard. "With the 
oblique illumination, we notice that the outer layers of the cor- 
tical substance, although opaque, are somewhat translucent, so 
that we can see through them into the deeper layers. This is of 
importance with regard to the consistence, for in the very soft or. 
the fluid cataract the dense white opacity reaches quite up to the 
capsule, and is not at all diaphanous. 

Von Graefe 1 calls attention to a peculiar cataract which is some- 
times met with in early infancy. Its diagnosis is of special im- 
portance, as it is very frequently complicated with lesions of the 

• "A. f. O.," i. 2, p. 256. 



CATARACT. 245 

deeper structures of the eyeball. It commences as a milky-white 
cloud in the outer portions of the cortical substance, and soon 
reaches quite up to the capsule. The opacity is either completely 
homogeneous, or studded with small white dots which extend close 
up to the capsule. The lens, which is at first somewhat increased 
in volume, soon diminishes again in size on account of the absorp- 
tion of its fluid constituents. In cases, therefore, in which the 
volume of the lens is much diminished, and considerable opacities 
are lodged in the central portions of the anterior capsule, the degree 
of sight and the state of the field of vision should always be care- 
fully tested prior to an operation, in order that the existence of any 
deep-seated lesion may be detected. This form is not unfrequently 
confined to one eye. 

The progress of cortical cataract is generally rapid, more espe- 
cially in children, in whom it may become mature in the course of 
a few weeks or mouths. In adults it may increase but slowly, par- 
ticularly if the stripes are narrow and few in number. Broad 
stripes and large flocculent opacities indicate a rapid progress. As 
cataract is not of very common occurrence even before the age of 
fifty, we should always ascertain whether it may not have been 
produced by some special cause, such as injury to the lens or in- 
ternal inflammation of the eye. If both eyes are affected, the urine 
should be tested for the presence of sugar, as diabetes is a not 
unfrequent cause of cataract. 

Cortical cataract is always soft. In children it may be almost 
fluid. Although its consistence increases with advancing years, it 
is generally free from a hardish nucleus up to the age of thirty or 
thirty-five, and sufficiently pulpy to be readily removed by linear 
extraction. 

When a mature cortical cataract has existed for some time, it 
may undergo certain retrogressive changes. Its fluid and fatty 
constituents may become absorbed, and the cortical substance be- 
come more dry and consolidated. As absorption proceeds, the 
cataract shrivels up, the anterior capsule becomes wrinkled and 
recedes from the pupil, so that a more or less deep posterior chamber 
is formed. 

The capsule sometimes looks like a little wrinkled bag, containing 
small white chalky chips of lens. In very young subjects, the 
greater portion of the lens may become absorbed, so that finally 
there is nothing left but a small white shrivelled disk, of a hard 
chalky consistence. This is the chalky or " siliculose" cataract of 
old writers. Although this form may occur simply as the result of 
the absorption of the softer constituents of an ordinary cataract, it 
is still more frequently met with in deep-seated inflammatory 
lesions of the eyeball, as, for instance, in the latter stages of irido- 
choroiditis. But the fluid constituents, instead of becoming ab- 
sorbed, may increase, the structure of the lens breaking down, so 
that the cataract may become extremely soft or even fluid, which 
is especially the ease in children. In adults, more particularly 




246 DISEASES OF THE CRYSTALLINE LENS. 

after the age of. thirty, the harder nucleus sets a limit to the process 
of softening, which can then only affect the cortex and not the 

whole lens. Now, if in such 
cases the cortical substance be- 
comes fluid, the hard yellow 
nucleus will sink down in it, 
and thus the so-called "Mor- 
gagnian" cataract will be pro- 
s , duced. [Fig. 92.] 

The chief characteristics of 
fluid cataract are, that the opa- 
city is of a milky-white or 
dirty gray color, that it is homogeneous, and that it reaches quite 
up to the anterior capsule, on the inner side of which are often 
observed small white dots. There are no opalescent stripes, and 
the anterior layers of the cortex are not translucent. 

III. The Nuclear or Hard Senile Cataract. — It has been already 
stated that after the age of from thirty to thirty-five the lens un- 
dergoes certain physiological changes. The nuclear portion be- 
comes firmer and more consolidated, and assumes a yellow tint. 
This condition may exist for many years without any marked 
increase, without deterioration of sight, or without any opacity 
being observable with the ophthalmoscope ; but the division between 
the physiological and pathological consolidation and cloudiness is 
only one of degree. When these senile changes increase to such an 
extent that the sight is perceptibly impaired, and when the opacity 
of the lens is progressive and becomes marked even bj 7 transmitted 
light, I think that we must then no longer consider it as a phy- 
"siological condition, but as commencing nuclear cataract. In the 
latter case, the nucleus presents a marked yellow or yellowish-brown 
tinge, and is easily distinguishable from the cortical substance, 
which may remain clear, except perhaps in the immediate vicinity 
of the nucleus. With the oblique illumination, the cataract will 
appear as a round yellow opacity, situated at some distance behind 
the pupil. The anterior layers of the cortical substance are trans- 
lucent and transparent, so that we can see through them into the 
Centre of the lens, and the pupil throws a deep shadow upon the 
surface of the opacity. The nuclear cataract may be very dark, 
even black in color, which is due to the imbibition of hsematine. 
The " black cataract" may easily be overlooked if the eye is not 
examined with the ophthalmoscope or the oblique illumination. 
In black cataract the prognosis of the success must be somewhat 
guarded, as it is not unfrequently complicated with inflammatory 
lesions of the deeper tunics of the eye, and a fluid condition of the 
vitreous humor. 

Pure nuclear cataract is but rarely met with. In the great 
majority of cases of senile cataract the cortex is also affected, so 
that we have in truth a mixed form — viz., a hard yellow nucleus 
with a more or less firm cortical substance. I think it well, how- 



CATARACT. 247 

ever, to retain the name of " nuclear" cataract for the senile form, 
as indicating the presence of a hardish nucleus. 

Senile cataract generally commences at the periphery of the lens 
in the form of small centripetal stripes, between which we may 
often notice smaller and shorter spikes, situated at the very margin 
of the lens. The stripes may run along the anterior or posterior 
surface of the lens, the interjacent substance being clear. The 
opacity gradually becomes more general, and involves more and 
more the centre of the lens ; the intervals between the stripes be- 
coming clouded and perhaps studded with small opaque dots or 
patches. As the cataract progresses, the distinction between the 
nucleus and the cortex becomes more marked, the former showing 
a distinct yellow tint. 

Sometimes the stripes commence in the posterior cortex, extend- 
ing from the margin to the posterior pole of the lens, where they 
coalesce; the opacity thus assuming a stellate appearance. The 
intervals between the stripes may remain transparent for some 
time, as also the nuclear portion of the lens, so that we can see 
quite to the back of the latter. The view of the background of 
the eye is of course obscured in the centre by the confluence of the 
stripes, but if the segments between them are clear, we may yet at 
the periphery distinguish the details of the fundus ; such forms 
are often extremely slow in their progress. When opacities com- 
mence at the posterior pole of the lens, either in the form of centri- 
petal stripes or of circumscribed spots or patches, the general con- 
dition of the eye should be carefully examined, as this form of 
cataract (posterior polar cataract) not unfrequently shows itself in 
the later stages of sclerotico-choroiditis posterior, retinitis pigmen- 
tosa, detachment of the retina, and other deep-seated lesions. The 
coexistence of any such complication would, of course, materially 
affect our prognosis of the result of an operation. 

We occasionally meet with incipient cataracts in which there is 
a marked difference between the amount of the opacity, according 
to whether the oblique illumination or the ophthalmoscope be used 
for examination. On account of the great opalescence of the stripes, _ 
the opacity is very apparent to the naked eye and with the oblique 
illumination ; yet, on testing the vision, we find it suprisingly 
good, and with the ophthalmoscope we can, with a little manage- 
ment, clearly distinguish the details of the fundus. I have noticed 
this peculiarity several times in myopic patients ; the progress has 
generally been very slow. 

In the majority of cases, one of the first symptoms noticed by a 
person affected with incipient cataract is, that distant objects 
appear somewhat indistinct and hazy, or as if surrounded by a 
halo. After a time, near objects also become indistinct, and in 
reading, the print has to be approximated closer to the eye or 
observed through a strong convex lens, in order that a larger 
retinal image may be gained. If the opacity is chiefly or entirely 
confined to the centre of the lens, the margin being clear, the 
patient will see best when his back is turned to the light, or when 



248 DISEASES OF THE CRYSTALLINE LENS. 

he shades the eye with his hand, so that the pupil becomes some- 
what enlarged. Dilatation of the pupil by a very weak solution 
of atropine will have the same effect. If the cloudiness be con- 
fined to the margin of the lens, the reverse will obtain ; the sight 
will be best when the pupil is small. 

Sometimes, persons suffering from incipient senile cataract, com- 
plain that they are getting myopic, requiring the aid of a concave 
glass in order to distinguish distant objects. The reason of this 
fact is somewhat doubtful, and can only be explained upon the 
supposition that there is some increase in the volume of the lens, 
which gives it a higher refractive power. 

It was formerly thought that senile cataract almost always com- 
menced at the centre of the lens, and extended thence towards the 
, margin. This opinion led to great mistakes, and caused incipient 
cataract to be often entirely overlooked. 

On examining a mature senile cataract with the oblique illumi- 
nation, we at once notice the presence of a yellow nucleus. Its 
size may be estimated from the extent of the yellow reflex, its 
hardness from the depth of the color. The darker the yellow tint, 
the harder and more compact will the nucleus be. The cortical 
substance is of a gray or bluish-white color, traversed by numerous 
centripetal opalescent stripes, and studded perhaps with small 
white dots or patches. 

The rate of progress of senile cataract is very difficult to determine 
with accuracy. It is far more rapid in the cortex than in the nucleus. 
Sometimes, years may elapse before it arrives at maturity. It 
may remain at an incipient stage for a very long time without 
apparently making any progress, and then suddenly advance very 
rapidly, arriving at maturity within a few months or even weeks. 
We must, therefore, always be upon our guard against giving a 
decided opinion as to when any given case of incipient cataract 
will be fully formed, and fit for operation. Patients are sure to 
ask this question, and we may fall into great mistakes by giving 
a decided answer. This can only be predicted with anything like 
certainty, when the progress of the case has been constantly watched. 
As a general rule, I may state that if the cortical substance presents 
broad, white opalescent stripes and large flakes or spots, the pro- 
gress is more rapid than if the stripes or spots are small and narrow, 
and the intermediate lens-substance clear. 

Senile cataract occurs most frequently after the age of 50 or 55, 
and sooner or later generally affects both eyes. 

"When a mature senile cataract has existed for some length of 
time, it may also undergo some retrogressive changes ; but these 
are far less than in the cortical cataract, for they only affect the 
cortical substance and not the nucleus, which becomes harder and 
firmer. The fluid constituents may be partially absorbed, and 
some of the elements may undergo a fatty or chalky degeneration, 
so that the cataract diminishes in thickness and becomes flatter, 
but is very coherent. The molecules are aggregated together into 
small masses, which become adherent to the inner surface of the 



TRAUMATIC CATARACT. 249 

capsule, or are often collected at the margin of the lens. They 
may prove in so far dangerous, that they are very apt to remain 
behind in the capsule when the cataract is extracted, and give rise 
to secondary cataract. In very rare instances, a great portion ot 
the cataract may be absorbed, and the sight of the patient mate- 
rially improved. In the majority of such cases, the yellow nucleus 
may still be seen shining through the cortical substance, but now, 
however, no longer in the centre, but sunk down to the bottom ot 
the capsule (Morgagnian cataract). If the cortical substance is 
gray, very opaque, and pretty uniformly studded with fine dots or 
patches, it may be considered as soft ; not, however, pulpy or dif- 
fluent, but friable, so that small coherent portions are apt to remain 
behind, and adhere to the pupil or the corneal section after the 
chief portion of the cataract is removed. 



2— TRAUMATIC CATARACT. 

When the capsule is perforated or torn by a sharp instrument, 
the aqueous humor is admitted to the lens substance, which may 
become rapidly opaque. If the perforation is extremely small and 
superficial, such as might be produced by a very fine needle, the 
danger may be but slight. The lips of the wound in the capsule 
may unite, and no permanent, or only a very limited, opacity may 
remain; but if the wound is larger, much aqueous humor is ad- 
mitted, and the lens will swell up very rapidly, and press upon the 
iris and ciliary body. The iris is often considerably lacerated, or 
protrudes through the corneal wound, and this greatly increases 
the irritation and danger of severe inflammation. Flakes of soft- 
ened lens matter, or broken portions of lens, fall into the anterior 
chamber, and, coming in contact with the anterior surface of the 
iris, produce great irritation ; or portions of lens matter may exude 
through or become entangled in the wound. The inflammation, 
which may involve the iris, ciliary body, and choroid, may assume 
either a purulent or a serous character. In the latter case, there 
may be more or less increase in the intra-ocular tension, with the 
attendant train of glaucomatous symptoms. In children the danger 
of secondary inflammation is less than in adults, as the lens is 
softer, the iris less impatient of pressure, and absorption more 
rapid; in fact, the lens may be almost entirely absorbed, so that 
finally there only remains a small, hard, white disk. The lens 
becomes more rapidly opaque in the young than in elderly persons. 
I have occasionally met with eases in youthful individuals, in 
which, a few days after the injury to the lens, the latter had be- 
come almost completely cataractous. The swelling of the lens is 
often very considerable, so that its volume is much increased ; the 
iris is consequently pushed forward and the anterior chamber di- 
minished in size. This pressure of the swollen lens upon the iris 
and ciliary body produces great irritation, and may give rise to 
severe irido-cyclitis. The danger is very great when a foreign 



250 DISEASES OF THE CRYSTALLINE LENS. 

body — e.g., a piece of gun-cap or a chip of eteel — is lodged in the 
lens, or, having passed through it, is fixed in the deeper tissues of 
the eye, as it is frequently followed by a most destructive inflam- 
mation. After any injury to the lens, the history of the accident 
should be inquired into, and if it was caused by a chip of steel, a 
shot, etc., the condition of the eye must be carefully examined, in 
order that we may, if possible, ascertain whether the foreign body 
be still in the eye, and whereabouts it is situated. After an injury 
to the lens, the condition of the eye must be anxiously watched. 
The tension of the eyeball, the state of the sight and of the field of 
vision must be frequently examined, so that the earliest symptoms 
of any glaucomatous complication may be detected, and, if possible, 
cut short. The danger of sympathetic ophthalmia must likewise 
be kept in mind. A traumatic cataract may also be produced 
through a simple contusion of the eye, without any laceration or 
rupture of the external coats of the eye. Thus a blow upon the 
eye or over the head from the fist, or some blunt body (a piece of 
wood, whip, etc.) may give rise to traumatic cataract. Special 
attention was called by Mr. Lawson to this fact some years ago, 
who recorded several instances of this kind. 1 In such cases, how- 
ever, the capsule is generally ruptured, in most instances, as was 
pointed out by Von Graefe, 2 at the periphery of the lens, just where 
the thick anterior passes into the thin posterior capsule. Some- 
times, however, no tear in the capsule can be detected. 



3.— CAPSULAR CATARACT, ETC. 

Capsular cataract presents a white, somewhat chalky appearance, 
and is situated in the area of the pupil. Strictly speaking, this 
term is inaccurate, for it would appear that the capsule itself does 
not become opaque, for although it may become wrinkled and 
changed in thickness, it retains its transparency, as has been shown 
by H. Miiller 3 and Schweigger. 4 According to Miiller, these opa- 
cities are not owing to any changes in the structure of the capsule 
itself, but are due to the deposition on its inner surface of new 
layers of a substance which is often much akin in its structure to 
that of the capsule, but is in other cases of a fibrous character. 
Certain hyaline changes also occur in the capsules of old persons, 
which are chiefly situated at the inner surface of the anterior cap- 
sule. If these transparent hyaline deposits should undergo here 
and there chalky degeneration, they become manifest to the ob- 
server, appearing as small whitish deposits on the anterior surface 
of the lens. 

Schweigger insists strongly on the fact that capsular cataract 

1 Vide " R. L. 0. H. Rep.," iv. 179 ; also Mr. Lawson's book, " On Injuries of 
the Eye," p. 130. 

2 "Berliner KHnische Wochenschrjft," 1864, 19. A translation of this Lecture 
upon Traumatic Cataract will be found in the "Ophth. Review," ii. 137. 

a " A. f. O.," ii. 2, 53, and iii. 1, 55. « Ibid. viii. 1, 227. 



CAPSULAR CATARACT. 251 

only occurs as a complication of a previous cataractous opacity of 
the lens. Thus, when the fluid constituents become absorbed in a 
retrograding cataract, the harder portions may become adherent 
to the inner portion of the capsule, and thus produce an opacity at 
the inner side of the latter, the capsule being here also somewhat 
wrinkled and perhaps thinned. This opacity is chiefly situated in 
the area of the pupil, and is of a whitish or whitish-brown tint, 
and incrusted with chalky deposits or fragments of cholestearine 
crystals, and its situation close behind the anterior capsule becomes 
very evident with the oblique illumination. The intra-capsular 
cells are generally unchanged, excepting they have become de- 
stroyed during the process of adhesion between the inner surface 
of the capsule and the lens substance. The diagnosis of this form 
of capsular opacity in retrogressive lenticular cataract is of much 
practical importance in performing the operation of extraction, for, 
on account of the toughness and adhesion of the capsule to the sub- 
jacent lens substance, sufficient laceration with the cj^stotome will 
be very difficult, and a displacement of the lens may easily occur. 
In such cases, it is better, therefore, instead of endeavoring to 
divide the capsule with the pricker, to seize its anterior layer with 
a pair of fine iridectomy forceps, and gently withdraw it, which 
will not only afford a sufficient opening for the ready exit of the 
lens, but also remove the opaque thickened capsule, which would 
have subsequently materially interfered with the sight. Or again, 
in such a case the extraction of the lens in its capsule may be indi- 
cated, for in these retrogressive cataracts the adhesion between the 
capsule and the zonula of Zinn is generally so much loosened that 
the lens escapes very readily in its capsule, there being the less 
fear of a rupture of the latter as it is generally abnormally tough 
and adherent to the lens. 

Capsular cataract is found most frequently in those opacities of 
' the lens which are complicated with irido-choroiditis, and here 
great proliferation of the intra-capsular cells occurs ; they may sub- 
sequently undergo fatty degeneration and finally disappear and be 
replaced by calcareous deposits ; the chalky degeneration of the 
lens not unfrequently taking its start from the capsule (Schweigger). 1 
As capsular cataract occurs most frequently in the latter stages of 
irido-choroiditis, the history of the case and the general condition 
of the eye, as well as the degree of sight and the extent of the 
visual field must be carefully examined before any operation is un- 
dertaken, in order that the presence of any deep-seated lesions (e.g., 
detachment of retina) may not be overlooked. 

Anterior central capsular cataract may be congenital, but is more 
frequently formed in early childhood, in consequence of a perfo- 
rating ulcer of the cornea. If it is congenital, and there are no 
traces of iritis or of an ulcer of the cornea, it is probably due to 
some intra-uterine arrest of development. But it is generally 
caused by an ulcer in the cornea, and occurs in this way, if an 

1 "Loc. cit.," p. 236. 



252 DISEASES OF THE CRYSTALLINE LESS. 

ulcer, which is situated at or near the centre of the cornea, per- 
forates the latter, the aqueous humor escapes, the iris and lens fall 
forward and come in contact with the cornea. Plastic lymph is 
effused in the ulcer, and a little nodule of this is deposited upon the 
centre of the capsule. As the pupil contracts on the escape of the 
aqueous humor, only the central portion of the capsule remains un- 
covered by the iris, and this is, therefore, the place where the 
cataract is formed. As the nutrition of the lens is impaired near 
the deposit of lymph from the disturbance in the osmosis, the super- 
ficial layers of the cortical substance in its vicinity become some- 
what opaque, the intra-capsular cells perhaps also undergoing pro- 
liferation, etc. The ulcer of the cornea heals, and on the aqueous 
humor becoming again retained, it tears through the adhesion be- 
tween the cornea and the capsule, the iris and lens recede to their 
former position, but the capsular opacity remains. Frequently the 
deposit of lymph on the capsule becomes absorbed, and only the 
opacity on the inner surface of the capsule and the contiguous 
portion of the lens remains behind, the capsule though changed in 
its thickness being transparent. Now if the cornea subsequently 
clears, the true origin of the capsular cataract may remain unsus- 
pected. But even in an apparently transparent cornea I have often, 
with the oblique illumination, been able to discover a trace of a 
central opacity, showing the seat of a former ulcer. Even, however, 
if the cornea should in after years be quite clear, this would not be 
a proof that there had not been a small central perforating ulcer, 
for we constantly find extensive and deeply situated corneal opa- 
cities clearing away perfectly in the course of time. Another 
objection which is sometimes urged against this view of the origin 
of central anterior capsular cataract is, that there could have been 
no perforation if no anterior synechia remains. But the very fact 
of the formation of the capsular cataract in this way, precludes the 
existence of an anterior synechia (at least in the centre), for the 
adhesion between the anterior surface of the capsule and the cornea 
must be so slight that the re-accumulation of the aqueous humor is 
sufficient to tear it through ; which could not occur if so much 
lymph was effused as to produce an auterior synechia. Moreover 
in very rare instances, of which I saw one several years ago at 
Prof. Arlt's, in Vienna, we may trace a very delicate thread of 
lymph from the anterior capsule to the posterior portion of the 
cornea. When the central capsular cataract is very prominent, and 
elevated above the surface of the capsule, it is termed '■'■'pyramidal 
cataract;'" but even in such cases Muller has found it covered by 
transparent capsule. Very superficial wounds of the lens may also 
produce anterior capsular cataract, if, together with the cataractous 
changes in the lens substance, the intra-capsular cells undergo pro- 
liferation. Mr. Hulke 1 thinks that it is produced in ophthalmia 
neonatorum in the following manner, it being remembered that the 
space between the cornea and the lens is only very slight: "In 

1 "R. L. 0. H. Rep.,"i. 188. 



CAPSULAR CATARACT.' 253 

ophthalmia neonatorum when the cornea becomes inflamed and 
swollen, its posterior surface may actually come in contact with 
the front of the lens, and then a dot of lymph poured out upon the 
latter by the inflamed cornea, or even the mere pressure contact, 
may give rise to opacity by preventing the proper nutritional osmose 
through the capsule." Mr. Hutchinson, 1 on the other hand, sup- 
poses that " the mere proximity of the inflammatory action on the 
surface of the conjunctiva and cornea suffices to disturb the nu- 
trition of the lens capsule, and to produce deposits." It is difficult 
to understand, however, why, if this were so, the disturbance of the 
nutrition, and the deposits should always be confined to a small 
portion of the capsule in the centre of the pupil, and should not 
also affect the more peripheral parts. 

Anterior capsular cataract may also appear after iritis, if an effu- 
sion of lymph has taken place into the area of the pupil, and the 
posterior synechise subsequently yield to the action of atropine, etc., 
the adhesions and deposits of lymph at the edge of the pupil may 
gradually disappear, while the central nodule of exudation in its 
area remains, and, on account of the disturbance of the nutrition 
of the lens at this point, may give rise to cataractous changes in 
the subjacent lens matter. 

Changes in the posterior portion of the capsule are of far less fre- 
quent occurrence than in the anterior. The opacities which are met 
with at the posterior pole of the lens (hence termed posterior polar 
cataract) are generally due to changes in the cataractous portions 
of the neighboring cortical substance, which may become intimately 
adherent to the capsule, or hyaline deposits may be formed upon 
the latter. In rarer instances, a new formation of cells is observed 
on the inner surface of the posterior capsule, being due to a prolife- 
ration of the intra-capsular cells which have extended themselves 
on to the posterior capsule (Schweigger). 2 But the posterior polar 
opacities may be situated in the most anterior portion of the vitre- 
ous humor close to the posterior capsule, being due to inflammatory 
or nutritive changes in the vitreous. In such cases, as Stellwag 3 
points out, tbe opacity presents a smooth and somewhat glistening 
aspect, whereas that dependent on deposits on the inner surface of 
the capsule is generally rough and granular, projecting perhaps 
somewhat into the lens substance. I have already called attention 
to the fact that these opacities, situated at or near the centraLpor- 
tion of the posterior, capsule, are most frequently due to some dis- 
turbance in the nutrition of the lens or vitreous humor, dependent 
upon chronic inflammations of the deeper tunics of the eyeball, and 
are often met with in the later stages of sclerotico-choroiditis poste- 
rior, retinitis pigmentosa, detachment of the retina, or remain after 
serous choroiditis. 
In very rare instances the opacity at the posterior pole of the lens 

1 Ibid. vi. 136. 2 "A. f. O.," viii. 

3 " Augenheilkunde," 3d edition, p. 153. 



251 DISEASES OF THE CRYSTALLINE LENS. 

may be congenital, and is then in all probability due to the imper 
feet retrogression of the hyaloid artery (Amnion). 1 

I will now pass on to the different operations suitable to various 
forms of cataract, commencing with the flap extraction ; but before 
so doing, I must touch upon certain important preliminary considera- 
tions. 

It is generally deemed important that a cataract, especially the 
senile form, should be mature before it is submitted to an operation. 
In mature cataract the opacity involves the whole lens, and the iris 
throws little or no shadow upon it. The sight is so much impaired 
that the patient is unable to distinguish the largest print, or to 
count fingers. If the cataract is immature, it will not come out en 
masse, but the transparent portions of lens substance are stripped off, 
and remain adherent to the capsule or the edge of the pupil. They 
swell up very considerably, and may produce great inflammation 
or a dense secondary cataract. These observations do not of course 
apply to zonular cataract, which may never become mature. The 
question now arises, what should be done if the cataract remains 
immature for a long time, yet is so advanced as greatly to impair 
vision? Can we hasten its progress? Undoubtedly, but we run 
some risk in so doing — a risk which should not, I think, be incurred 
except under peculiar circumstances. If, for instance, a person who 
is entirely dependent upon his sight for his means of subsistence is 
affected with double cataract, whose progress is extremely slow, 
and which, though very immature, is sufficiently dense to prevent 
his following his customary occupation, it may be advisable to has- 
ten the progress of the cataract. This is to be done by gently 
pricking the lens with a fine needle, so as to slightly divide the cap- 
sule and the lens substance, and admit a little aqueous humor. 
This may be repeated several times, care being taken not to divide 
the lens too freely at one sitting, lest a severe iritis or irido-cho- 
roiditis be set up. The pupil is to be kept widely dilated with atro- 
pine, and the state of the eye narrowly watched, for fear of any 
severe inflammatory symptoms ensuing. It is safer still, as was 
recommended by Von Graefe, to make a preliminary iridectomy, 
so as to afford more room for the swelling up of the lens ; moreover, 
the existence of an iridectomy would prove of advantage when the 
final operation of removal of the lens is performed. This proceed- 
ing is, however, accompanied by the disadvantage that it necessi- 
tates two operations, with an interval of some weeks between them ; 
which often proves of much inconvenience and anxiety to patients 
who come from a distance, or to those who are of a very timid and 
nervous character. Indeed, not many patients will submit to such 
repeated operations. Since the introduction of Von Graefe's new 
operation, I must confess that I have paid less heed to the necessity 
of waiting with the operation until the cataract is quite mature, for 
I have obtained excellent results where this has not been the case ; 

4 "A. f. O." iv. 1, 59. 



CAPSULAR CATARACT. 255 

indeed, I have removed with perfect success lamellar cataracts in 
persons above the age of 25. As a rule, I should, however, prefer 
to operate on a cataract, which is quite mature, as it affords a 
better chance of complete removal. Again, instead of hastening 
the progress of the cataract, the lens may be removed in its capsule, 
which obviates the danger of unripe portions being left behind. 
"Whilst on the one hand, it is dangerous to operate too early, it may 
also be wrong to wait too long after the cataract is fully formed. 
In children especially, we should operate early, for otherwise the 
sight and the sensibility of the retina may permanently suffer, and 
oscillation of the eyeball (nystagmus) may also be produced. Later 
in life, a mature cataract may exist for very many years, without 
the sensibility of the retina being affected by this passive exclusion 
from the act of vision. But in children it is different ; in them 
the passive suppression of the retinal image produced by the cata- 
ract, appears to exert a similar influence upon the sensibility of the 
retina, as the active suppression which occurs in cases of squint, and 
which often rapidly leads to great amblyopia. Again, we have seen 
that when a mature cataract has existed for some time, it may 
undergo certain retrogressive changes, its fluid constituents may 
become absorbed, fatty or calcareous masses may be collected at its 
margin or adhere to the capsule, and remain behind when the lens 
is removed, giving rise to inflammatory complications and secondary 
cataract. It is wiser, therefore, to operate before such secondary 
changes have set in. 

Should we operate upon the one eye if the other is quite free 
from cataract? I think it is advisable, where the operation is 
almost certain of succeeding, as, for instance, in the division or 
linear extraction of cataract of young- individuals; for the operated 
eye, although differing greatly in its state of refraction from the 
other, will still assist somewhat in the act of vision. The visual 
field will be extended, and the fear of amblyopia will be removed, 
as the eye may be separately practised with suitable convex glasses. 
Moreover, the personal appearance will be improved. 

Should both eyes be operated upon at the same time in eases of 
double cataract ? It is doubtless safer to operate only on one eye 
at a time. Unsuspected peculiarities in the constitution or the 
temperament may show themselves in the course of the treatment, 
a prior knowledge of which may prove of great value in the treat- 
ment of the other eye, and lead us, perhaps, to select a different 
mode of operation. On the other hand, it has been urged that it 
is very rare to see a bad result {e.g., suppuration of the cornea) in 
both eyes, if they have been operated upon at one sitting. In this 
point we must be much guided by personal circumstances. It may 
be very inconvenient for the patient to have the operations divided, 
and the treatment thus extended over a long period ; or, if he be 
in a weak and nervous condition, it may be unwise to submit him 
to the anxiety of two operations. If one cataract is mature and 
the other only partially formed, but yet sufficiently opaque to pre- 
vent the patient from following his customary employment, it 



256 DISEASES OF THE CRYSTALLISE LENS. 

may be necessary to operate upon the former, so as to enable him 
speedily to resume his avocations whilst the other is advancing to 
maturity. If no such necessity exists, we generally wait till both 
cataracts are mature. 

It is of little consequence at what time of the year extraction is 
performed. Formerly it Avas thought advisable to operate chiefly 
in the spring and early summer, but we now operate all the year 
round, except during intensely hot or very cold weather, for ex- 
tremes of temperature are not favorable for the progress of the case. 
If the weather is hot and oppressive, the patients become very 
restless, irritable, and exhausted. The time of day is also of little 
or no moment, although I myself prefer the morning, for we can 
then judge by the evening whether or not any primary inflamma- 
tory reaction is likely to set in, and if so, we can without loss of 
time endeavor to check it. 

Before an operation is decided upon, the general health must be 
examined, and if this be at all impaired we must endeavor to im- 
prove it as much as possible prior to operating. It is of the greatest 
advantage for the result of the operation to have the patient in 
perfect health. The chief fear is, that in a weak and decrepid 
person the vitality of the cornea may be so low that its healing 
power is greatly impaired, or that it may even slough after the 
operation. A symptom of some importance, as being indicative of 
this low vitality, is the loss of elasticity of the skin, so that if we 
pinch up a fold of skin on the back of the hand it does not fall 
back at once, but remains wrinkled. Severe cough or chronic 
bronchitis contra-indicate flap extraction. If double cataract occurs 
in youth or early middle age (before the age of 45), and if its for- 
mation is rapid, we must examine whether the patient is suffering 
from diabetes, for this is a not unfrequent cause of cataract. The 
lens becomes affected chiefly in the later stages of the disease, when 
the health is much broken. The cataract is generally softish, and 
its formation rapid. In old persons a more or less large and hard 
nucleus will be present, but diabetic cataract does not show any 
special characteristics. If diabetes is found to exist, special care 
must be taken to examine the sight and the field of vision, as af- 
fections of the retina and optic nerve not unfrequently occur in the 
course of the disease, and may therefore coexist with the cataract 
and render the prognosis of the result of an operation unfavorable. 

The general condition of the eye should always be carefully 
examined before an operation for cataract is determined upon. 
The tension of the eyeball, the degree of sight, and the state of the 
field of vision must be ascertained, so that the presence of any 
deep-seated lesion may not escape detection. Otherwise, we might 
fall into the reprehensible and unjustifiable error of operating upon 
an amaurotic eye. 

Should the patient be suffering from epiphora, dependent upon 
some affection of the lachrymal apparatus, or from inflammation of 
the eyelids or the conjunctiva, this should, if possible, be cured 
prior to the operation, as any such complication not only enhances 



CAPSULAR CATARACT. 257 

the difficulties of the after-treatment, but may even endanger the 
result of the operation. 

The method to he pursued in examining the perception of light 
and the condition of the field of vision, in a person affected with 
mature cataract, has been already explained in the Introduction 
(p. 24). Such a person should be able to distinguish a low burning 
lamp at a distance of 10 or 14 feet, if his perception of light is good, 
and there is no lesion of the deeper tunics of the eye. If there is 
any marked deterioration of the perception of light, or of the field 
of vision, the history of the case must be carefully inquired into, 
in order that we may detect the presence of any complication. If 
the upper or lower half of the field is lost, we must suspect detach- 
ment of the retina ; if the lateral halves are wanting, an affection 
of the optic nerves. Cerebral amaurosis generally causes a con- 
centric contraction of the field, or the latter may commence at the 
temporal side. In glaucoma the contraction of the field begins 
almost invariably at the nasal side. If such a contraction of the 
field exists, the tension of the eyeball must be ascertained, and the 
other symptoms of glaucoma searched for. If glaucoma attacks an 
eye affected with mature senile cataract, the glaucoma must first 
be cured by an iridectomy, and then subsequently, at the interval 
of several months, the cataract should be removed. But this must 
not be done until all symptoms of irritation and increased tension 
have subsided, and the improvement in the nutrition and circula- 
tion of the eye has been firmly re-established. ( Vide the article 
on " Glaucoma.") 

The pupil should be dilated by atropine before the operation. In 
a very presbyopic eye, with an exceedingly shallow anterior cham- 
ber, there is always some danger, even to an expert operator, of 
wounding the iris either before the counter-puncture is made, or 
whilst the flap is being formed. Wide dilatation of the pupil is 
the best safeguard against such a danger, for the iris will be re- 
moved out of the way of the puncture, the counter-puncture, and 
the line of incision. "When the aqueous humor flows off, the pupil 
again contracts somewhat ; but this will not be of much conse- 
quence, as the section should by this time be nearly completed. 
The degree of rapidity with which the pupil dilates under the in- 
fluence of atropine also affords us a hint as to the probability of 
iritis. Von Graefe has called attention to the fact that if the iris 
is easily and quickly affected by atropine, there is less tendency to 
subsequent iritis than if its action is tardy and imperfect. 

The patient should be operated upon in the recumbent position, 
being placed either on a couch or in his bed. In the Hospital I 
prefer operating in the ward, as there is considerable risk of the 
dressing being disturbed in the removal of the patient from the 
operating theatre. The light should, if possible, come from the 
side, for this dazzles the patient less, and causes much less reflection 
upon the cornea than when it comes from the foot of the bed or 
from a skylight. The latter, indeed, is the worst light of all for 
eye operations, more especially those of a very delicate nature. 
17 



258 DISEASES OF THE CRYSTALLINE LENS. 

The position which the operator is to assume with regard to the 
patient will depend upon which eye is to be operated on, and upon 
the fact whether the surgeon is ambidexter or not. Some think 
it a sine qud non that an oculist should be able to use both hands 
equally well ; but this is not the case. By changing his position, 
he may always operate with the right hand, upon either eye, either 
by the upper or lower section. Yet I strongly advise every surgeon 
to practise operating with the left hand, for he will constantly find 
it a great advantage to be able to use it well. For instance, in 
performing iridectomy it is very desirable that he should be able 
to grasp the iris with the forceps held in the left hand, and snip it 
off with the scissors in the right, or vice versd. Still, if he finds 
after much practice on the dead subject, that he cannot operate for 
extraction nearly so well with the left hand as with the right, he 
should not endanger the result of the operation by using the left 
hand. If the left eye is to be operated on (either by the upper or 
lower section), the surgeon, if he is not ambidexter, is to seat him- 
self on the couch in front of the patient, and on his left side. If 
he operates with his left hand, he will stand behind the patient. 
The latter position is also to be assumed when the right eye is to 
be operated on. 

4.— FLAP EXTRACTION. 

The section may be made either upwards or downwards, as the 
advantages are pretty evenly balanced. The downward section is, 
however, the easier of the two. There is often, moreover, an un- 
controllable tendency for the eye to roll upwards beneath the lid, 
which materially enhances the difficulties of the operation, and 
may greatly embarrass the operator, especially during the laceration 
of the capsule and the exit of the lens. The chief advantages of 
each mode of operating may be briefly stated to be as follows : In 
favor of the upper section [Fig. 93], it may be urged that the broad 



[Fig. 93.] 




smooth surface of the inside of the upper lid will lie in contact 
with the section and support it, and thus facilitate the union; 
whereas the edge of the lower lid may rub against the lips of the 
incision, or even get between them, set up considerable irritation, 



FLAP EXTRACTION. 259 

and prevent the union by first intention. Again, if in the upper 
section the wound does not unite by first intention, either from 
the occurrence of prolapse of the iris, or suppuration of the edge of 
incision, the cicatrix thus produced will be hidden by the upper 
lid. But to this it may be objected, that if the prolapse has pro- 
duced much distortion of the pupil, the latter may be so much 
covered by the upper lid as greatly to impair the vision ; so that 
it will be necessary to make an artificial pupil in another direction. 
The advantages offered by the lower section [Fig. 94] are, that it 




is more easy of performance ; as are also the division of the capsule, 
the exit of the cataract, and the removal of the remains of cortical 
substance. The cornea is, moreover, less liable to be bruised, and 
should suppuration of the cornea occur, it is more likely to limit 
itself than in the upper section. Bearing these points in mind, I 
should advise the beginner at first to perform the lower section, 
until he has acquired sufficient dexterity and experience in ope- 
rating to give each method a fair trial. 

The instruments required for flap extraction are — 1. An extrac- 
tion knife. 2. A pair of forceps for fixing the eyeball. 3. A pricker 
or Graefe's cystotome, for dividing the capsule. 4. A curette,, 
which, for convenience sake, is fixed to the other end of the pricker, 
5. A blunt-pointed secondary knife. 6. A blunt-pointed pair of 
scissors. 

Various forms of extraction knives are recommended by differ- 
ent operators. I myself prefer Sichel's knife (Fig. 95). It is rather 

Fig. 95. 




long and narrow, and increases regularly, but not too abruptly, 
from point to heel, so that the flap is formed by simply pushing 
the blade on through the anterior chamber until the section is 
completed. Its wedge shape fills up the gap, and prevents the 
premature escape of the aqueous humor. The handle is to be 
lightly held between the thumb, fore, and middle finger,, the thumb 
being slightly bent outwards at the joint. The elbow must be 



260 DISEASES OP THE CRYSTALLINE LENS. 

kept close to the side and the wrist steady, so that all movements 
are made from the fingers and hand. 

I will now proceed to a description of the operation, and I shall 
throughout suppose that the right eye is to he operated upon by 
the upper section. 

I shall enter somewhat at length into the description of the 
mode of operating, the accidents which may occur, and the princi- 
ples which should guide us in the after-treatment, because most of 
these questions are of importance in every mode of operating for 
the extraction of cataract ; hence it is absolutely necessary that the 
surgeon should be acquainted with them, even although he may 
entirely abandon the common flap extraction for Von Graefe's new 
operation. 

The operator should stand or sit behind the patient, who is to 
be placed in the recumbent position. If he is about to operate 
without fixation, he will hold the upper eyelid with the forefinger 
of his left hand, drawing it upwards and away from the eye. The 
tip of the second finger is to be placed gently against the sclerotic 
on the nasal side of the cornea, so as to prevent the eye from rolling 
too far inwards. An assistant is to draw the lower eyelid down 
without everting it. Many of our best operators do not employ 
fixation, and generally make admirable sections ; but yet cases will 
occur in which even the most skilled operator does not make the 
counter-puncture just at the desired point. The chief difficulty 
in operating without fixation is, that the eye may roll swiftly 
inwards directly the puncture is made, or even before, so that the 
cornea becomes almost hidden in the inner canthus, and the knife 
has to traverse the anterior chamber and to make the counter- 
puncture, without the operator being able to see its course. This 
will prove extremely embarrassing to the beginner, and may even 
unnerve him for the remainder of the operation. I should, there- 
fore, strongly recommend him to fix the eyeball, as this greatly 
facilitates the first part of the operation, and as there is not the 
slightest objection to his doing so. It has been objected that the 
fixation often produces pain and much irritation, but this will 
hardly occur, if it be gently and carefully done. Moreover, so 
sensitive an eye would prove most difficult to operate upon without 
fixation. Afterwards, when the operator has gained more confi- 
dence and dexterity, he may do without it, if he chooses. Various 
instruments have been devised for this purpose, but the common 
fixing forceps are the best. Their use in this operation has long 
been advocated by Von Graefe, and more lately by Mr. France. 
As soon as the counter-puncture is made, they are to be removed, 
for the eye is then completely under our control. The operator 
should rather fix the eye himself than entrust this to an assistant, 
for it is impossible that their hands can work together with such 
unanimity as if both hands are guided by the same volition. If 
fixation be employed, an assistant must hold the lids. If the right 
eye is to be operated on, he should stand on the left side of the 
patient, and place the tips of the fore and second finger of his right 



FLAP EXTRACTION. 



261 



hand upon the edge of the upper lid (without touching the lashes), 
and draw it gently upwards and a little inwards, away from the 
eyeball. If the lids are at all moist, a piece of linen may be folded 
round the fingers, so as to prevent their slipping. The lower lid 
is to beheld with the forefinger of his left hand. But if the as- 
sistant is not dexterous and trustworthy, and the surgeon cannot 
operate well without fixation, the spring speculum may be em- 
ployed to keep the lids apart, but I am rather afraid of it, as it is 
apt to irritate the eye, and to press upon the eyeball. 

The operation is divided into three periods— 1st. The formation 
of the flap ; 2d. The laceration of the capsule ; 3d. The removal of 
the lens. 

First Period. — Let us again assume that the right eye is to be 
operated upon by the upper section, and that the operator will fix 
the eye. Holding the forceps in his left hand, he seizes a fold of 
conjunctiva and subconjunctival tissue near the lower edge of the 
cornea (as in Fig. 96, after France), or, as I prefer it, rather more 
to the nasal side, and draws the eyeball gently down, so as to bring 
the cornea well into view. Then, holding the knife lightly in his 
right hand, and steadying the 
latter by placing his ring or 
little finger against the temple, 
he enters the point at the 
outer side of the cornea about 
a quarter of a line from its 
edge, and just at its transverse 
diameter, and then carries the 
blade steadily and rather slow- 
ly across the anterior chamber 
to the point of counter-punc- 
ture, keeping it quite parallel 
to the iris. Special care must 
be taken not to rotate it or to 
press upon its edge, but rather 
to press upon the back of the 
blade, as if, in fact, he were 
wishing to cut with this. If this be done, the blade will be pushed 
steadily on and fill up the gap, thus preventing the premature 
escape of the aqueous humor. I find this pressing upon the back 
of the blade one of the most difficult things for the young operator 
to acquire. The eye of the operator is not to be kept fixed upon 
the point of the knife, but upon the point where he wishes to 
make the counter-puncture, for this will insure the knife being 
brought out at the desired spot, which should lie slightly in the 
upper half of the cornea, about a quarter of a line from its edge. 
As soon as the counter-puncture is made, the forceps are to be 
removed and the handle of the knife turned back towards the 
temple, the blade being pushed steadily on until the section is all 
but finished. When only a small bridge of cornea remains undi- 
vided, the section is to be slowly completed by turning the edge of 




262 



DISEASES OF THE CRYSTALLINE LENS. 



the knife a little forwards, and, instead of carrying it straight on, 
drawing it back from heel to point until the section is finished. 
Von Graefe insists especially upon the advantage of doing this, 
for as the narrowest part of the blade thus issues last from the 
incision, the flap will be less elevated than by the broad part ; 
moreover, the altered position and direction of the knife cause a 
relaxation in the tension of the muscles of the eye, and thus 
diminish straining. "When the incision is completed, the upper 
lid is to be gently and carefully dropped, so that it may not catch 



Fig. 97. 



Fig. 98. 




in between the lips of the wound and evert' the flap. 
The patient having been calmed by a few words of 
encouragement, we pass on to the 

Second Period, the Opening of the Capsule. — This may 
be done either with the pricker (Fig. 97, which repre- 
sents this instrument, together with the curette, which 
is placed at the other end of the handle), or with 
Graefe's cystotome. The patient is directed to look 
well down to his feet, and the upper lid being 
slightly lifted, the pricker is introduced with its 
blunt angle downwards. When arrived at the inner 
side of the pupil, it is slightly rotated, so as to turn 
its point against the capsule, which is to be divided 
across as far as the outer edge of the pupil by one or 
more incisions. The point is then turned downwards, 
and the instrument carefully removed, so as not to 
entangle it in the iris or cornea. For flap extraction 
I prefer Graefe's cystotome (Fig. 98 — beside it is an 
enlarged view), as it makes a freer opening, and as we 
need not change its horizontal position in lacerating 
the capsule, whereas the handle of the pricker requires 
to be a little elevated, which causes more or less gaping 
of the section. Care must be taken not to press the 
point of the pricker or cystotome against the lens in 
dividing the capsule, otherwise we may cause a dis- 
placement of the lens into the vitreous humor. 

Third Period — Removal of the Lens. — The patient 
being again directed to look downwards, the point of 
the forefinger or the end of the curette, is to be placed against the 
lower lid, and a gentle, but steady, pressure made upon the globe. 
[Fig. 99.] The point of the other forefinger may be placed on 
the upper portion of the eyeball, so as to regulate and alternate 



FLAP EXTRACTION. 



263 




the pressure to a nicety. The pressure on the lower lid should be 
at first backward, in order that the upper edge of the lens may be 
tilted slightly forward against 
the upper portion of the pupil, 
which gradually dilates and 
permits the presentation of the 
lens. The pressure is then di- 
rected a little more upwards 
and backwards, so that the lens 
advances through the pupil into 
the anterior chamber, and makes 
its exit through the incision. 
If it halts a little in its course 
through the section, it may be 
extracted with the curette. 
The pressure throughout should 
be steady, but very gentle, in 
order that the lens may not be 
violently jerked out, which is generally accompanied by rupture 
of the hyaloid membrane and an escape of vitreous humor. When 
the lens has been removed, we should examine its outline to see 
whether this is perfect, or whether it is irregular or notched, as 
the latter shows at once that portions of the cortical substance 
have remained behind. If the cataract is not quite mature, frag- 
ments of cortex are apt to remain in the capsule, or are stripped 
off during the passage of the lens through the pupil or the corneal 
incision, to either of which they may cling. These portions should, 
if possible, be removed, as they are very apt to set up iritis or to 
give rise to secondary cataract. The lids are, therefore, to be 
closed and lightly rubbed in a circular direction, so that any little 
flakes remaining behind the iris may be brought into the area of 
the pupil, whence they are to be gently removed with the curette, 
as likewise any portions adhering to the lips of the wound. The 
vision of the patient may also be tested by trying if he can count 
fingers, and if it is not as good as might be expected, we may ex- 
amine again as to whether remnants of lens substance still linger 
behind. 

We must now briefly consider what course is to be pursued if any 
untoward circumstances arise during the different steps of the ope- 
ration. 

Under the following circumstances, it is advisable to withdraw 
the knife at once, and to postpone the operation until the wound is 
united : 1. If the puncture is too near the edge of the cornea, or in 
the sclerotic. 2. If it is too far in the cornea, so that the flap would 
be too small. 3. If the aqueous humor spirts out when the point of 
the knife has only just entered the anterior chamber, for the iris 
will then fall forward upon the knife, which would become entan- 
gled in it, so that it would be impossible to finish the section with- 
out lacerating the iris considerably. 4. If the point of the knife is 
so blunt that it will not readily make the counter-puncture. 



264 



DISEASES OF THE CRYSTALLINE LENS. 



Should the aqueous humor escape directly the counter-puncture 
has been made, the section may yet be finished without wounding 
the iris, by placing the point of the fore or middle finger of the 
other hand upon the edge of the blade, and pushing the iris oft' from 
it as the section is being slowly completed. If, however, it is im- 
possible to avoid wounding the iris, it is better to cut boldly through 
it, as this is far less apt to excite iritis than if the knife becomes 
entangled in it. If the counter-puncture is too close to the sclerotic, 
the knife must be slightly drawn back, and another counter-punc- 
ture made, or the size of the section be diminished by turning the 
edge of the blade slightly forwards in finishing the flap. This 
should also be done when the couuter-puncture is too low. If it be 
too high, the flap will be too small, and this may be remedied (1) 
by making another counter-puncture a little lower down, (2) by 
turning the edge of the blade back in cutting out, or (3) by enlarg- 
ing the section downwards with a secondary knife or a pair of blunt- 
pointed scissors. The last proceeding is to be preferred if the 
counter-puncture is much too high. If we purpose doing this, the 
section is to be continued until only a little bridge of cornea is left 
standing (Fig. 100 a.). The knife is then to be withdrawn, and the 
section enlarged by dividing the cornea to the required extent at 
the counter-puncture with the probe-pointed secondary knife (Fig. 
101), or with blunt-pointed scissors. The advantage of leaving the 



Kg. 100. 



Fig. 101. 




little bridge standing is, that it will keep the cornea tense, and 
prevent its yielding before the knife or scissors. The bridge is then 
to be divided, or, before so doing, the capsule may be opened. The 
size of the flap should always be noted before the section is com- 
pleted, so that we may enlarge it in the above manner if necessary. 
If the section is too small to permit the ready exit of the lens, there 
is much danger of rupture of the hyaloid membrane and escape of 
vitreous humor, and of bruising the iris and cornea. It is also 
advisable to leave the bridge standing if the patient is very unruly, 



FLAP EXTRACTION. 



265 



[Fig. 102.1 
7 



A 



and strains greatly as we are making the section. A few moments' 
rest will generally suffice to restore his quietude, and then the 
bridge may he divided. 

If the lens does not, at the third period, readily present itself in 
the pupil, we must on no account attempt to force this by pressing 
strongly on the eye ; but we must lacerate the capsule again, and 
more freely than before. If the capsule be so tough as not to be 
readily torn with the cystotome, it sometimes comes 
away with the lens, or it may be divided with the point 
of the knife, or be afterwards removed with a hook or a 
pair of iris forceps. 

If a little vitreous humor escapes with the lens, it is 
but of slight consequence as far as the immediate result 
of the operation is concerned. Some operators snip off the 
protruding portion of vitreous close to the incision, but 
I think it best not to do so, as it is simply followed by 
a fresh oozing out of vitreous ; I therefore only close the 
eye at once, and apply a firm compress bandage over it. 
But it is very different if it escapes before the lens, for 
then it will push the latter aside, so that it may even 
fall to the bottom of the vitreous humor. If this acci- 
dent should occur, a hook [Fig. 102] or scoop should be 
passed behind the lens, and the latter gently " fished 
out." It should be extracted at all hazards, for if it re- 
mains behind it is but too likely to set up a most destruc- 
tive and painful panophthalmitis. Many operators do 
not consider it of much consequence, if even a consider- 
able amount of vitreous is lost in an operation of extrac- 
tion of cataract. But there is no doubt that it is always a 
source of great danger to the future safety of the eye, for 
it not only frequently induces an insidious form of irido- 
choroiditis, or inflammatory or suppurative changes in 
the vitreous, but it is also, accordiug to Iwanoff, 1 gene- 
rally followed by detachment of vitreous, which may lead 
to detachment of the retina. This is likewise proved by 
the interesting and important experiments of Gouvea 2 
on the eyes of animals. 

After the exit of the lens, the corneal flap sometimes 
becomes wrinkled and collapsed, so that it falls away 
from the line of incision. This wrinkling is due either 
to decrease of the intra-ocular tension, or to a diminu- 
tion in the elasticity of the cornea. Von Grraefe lays 
great stress upon the importance of this symptom, con- 
sidering it unfavorable if the collapse be at all considerable, for he 
has found that suppuration of the cornea often occurs in such cases. 
If we therefore find, in a case of double cataract which is to be 
operated on at one sitting, that the cornea of the first eye becomes 
much wrinkled after extraction, it will be wise to submit the other 



"A. f. O.," xv. 



8 Ibid., xy. 1. 



266 DISEASES OP THE CRYSTALLINE LENS. 

eye to a different mode of operation. In such cases, also, great care 
must be taken that the flap is not turned back when the upper lid 
is let down. If the iris protrudes between the lips of the wound 
after removal of the lens, or if the pupil is distorted, the lids should 
be closed and lightly rubbed in a circular direction, so as to replace 
the iris, and restore the regularity of the pupil. If the prolapse 
still persists, it may be gently replaced with the curette. But if 
all our efforts prove unavailing, it is by far the best course to draw 
it out a little further and snip if off. The iridectomy will not be of 
the slighest disadvantage, more especially in the upper section ; in 
fact, it may prove of positive advantage, not only in favoring the 
cure, but also in exposing remnants of lens substance which may 
be situated behind the iris, and have, perhaps, caused the prolapse; 
whereas the occurrence of prolapse after extraction is one of the 
chief dangers and annoyances of this operation. The protruding 
portion of iris sets up considerable irritation, and prevents, perhaps, 
the union of the section, the aqueous humor flowing off through 
the fistulous opening ; and this constant irritation may set up iritis 
or irido-cyclitis. Even if the iris unites with the section, a broad 
unsightly cicatrix will be left, the pupil being, perhaps, greatly dis- 
torted or almost obliterated. To prevent all these untoward com- 
plications, I strongly advise the removal of a portion of the iris if 
the prolapse cannot be easily returned, or if the iris has been much 
contused by the exit of the lens, or by our endeavors to restore the 
prolapsed portion. Dr. "Williams, of Boston, IT. S., unites the edges 
of the corneal wound by a very delicate suture, which keeps the 
lips of the incision in contact, facilitates the union, and diminishes 
the risk of prolapse. 

Hemorrhage into the vitreous humor is a disastrous occurrence. 
It may take place either at the time of the operation, or some hours 
afterwards. The patient complains of a sudden sharp pain, a gush 
of vitreous takes place, followed by blood, and the eye is lost. In 
such cases there generally exists a diseased condition of the cho- 
roidal and retinal vessels, detachment of the retina, etc. 

The after-treatment of flap extraction is a subject of great im- 
portance, as much may be done by timely care and attention. As 
the rules with regard to the after-treatment of cases of flap extrac- 
tion also apply more or less to those in which some other mode of 
extraction is performed, I shall enter somewhat at length upon this 
subject ; and as the after-treatment of the different operations for 
cataract involves the same principles, I shall lay down certain- 
broad general rules of treatment, which will, however, require modi-, 
fication according to the exigencies of particular cases. It being 
of consequence to detect and combat any unfavorable symptoms at 
the earliest stage, the surgeon should visit the patient very fre- 
quently during the first few days after the operation, and, if pos- 
sible, himself change the dressings, so that he may watch the 
condition of the lids, the quantity and character of the discharge, 
etc. At one time the antiphlogistic treatment was in great repute. 
Local and general depletion were had recourse to, and perhaps 



FLAP EXTRACTION. 267 

repeated several times, upon the slightest appearance of pain or in- 
flammatory symptoms. But now this mode of treatment has justly 
fallen into disuse. Our primary object is to obtain adhesion of the 
corneal flap by the first intention, and this will take place far more 
readily in a strong healthy person, than in one who is weak and 
decrepid ; nearly one-half of the cornea has been divided, and for 
a time the other half has to carry on the nutrition of the whole, 
and to assist in the process of union. It must also be remembered 
that this operation is generally performed in persons above the age 
of 50 or 55, and even indeed in the very aged, whose vital powers 
will not bear depression. The geueral health and the reparative 
powers of the system must therefore be sustained. The better and 
stronger the patient's constitution is, the more favorable may be 
the prognosis of the result of the operation. Even the florid, turgid, 
apoplectic-looking individual warrants a better prognosis than the 
very aged, decrepid person, whose general health is poor and feeble, 
whose cheeks are pale and shrunken, whose arteries are rigid and 
skin unelastic. Von Graefe also considers the prognosis less favor- 
able if the eyeball is deep-set and sunken, and the diameter of the 
cornea short ; for in such cases flaccidity and wrinkling of the 
corneal flap, and suppuration of the cornea, are of not unfrequent 
occurrence on account of its feeble nutrition. 

The after-treatment must be varied according to the general 
health, constitution, and habits of the patient. The diet should, 
from the commencement, be light, nutritious, and easily digestible. 
Meat may be allowed once daily ; it should, however, be finely 
minced, so that there is no need for mastication, which would dis- 
turb the quietude of the eye. Good beef tea or mutton broth may 
be given occasionally during the day, but slops are, as a rule, to be 
avoided. But whilst we endeavor to sustain the patient's strength, 
we must not fall into the opposite error of over-feeding him. In 
a very plethoric and full-blooded individual, especially if marked 
inflammatory and febrile symptoms manifest themselves, a strictly 
antiphlogistic regimen must be observed. With regard to stimu- 
lants and beer, we must be entirely guided by the patient's con- 
. stitution and habits. It is very unwise to cut off all stimulants 
from an individual who has always, and perhaps largely, indulged 
in their use; we should allow him a moderate amount of his cus- 
tomary beverage, watching the while its effect, and diminishing or 
increasing the quantity as the case may demand. In feeble, de- 
crepid persons, stimulants and malt liquor, together with a good 
nutritious diet, often prove of great service ; quinine and ammonia 
being also given. 

It is well to administer a gentle purgative the day before the 
operation, so that the bowels may not require to be opened for a 
day or two after the latter. A mild dose of castor-oil should then 
be given, in order to prevent any straining ; and this may be re- 
peated if necessary. 

When the operation has been concluded, the patient is to be 
placed in bed in a darkened room. At night, his hands should be 



288 DISEASES OF THE CRYSTALLINE LENS. 

care being taken that it is not persisted in too long. If the pain 
does not yield to this treatment, a leech or two should be applied 
to the temple. On the second day atropine drops should be pre- 
scribed. The patient may generally leave his bed on the second or 
third day, but this will depend upon individual circumstances, and 
upon the fact as to whether he can have proper supervision. With 
some patients it is advisable to permit their leaving the bed even 
the day after the operation, but it is always wiser to err on the 
side of safety. The general rules laid down for the after-treatment 
of flap-extraction also apply to Von Graefe's operation. 

Dr. Taylor, of Nottingham, has operated by a method somewhat 
similar to that of Von Graefe (but quite independently of him) since 
the summer of 1865, indeed both appear to have begun about the 
same time. 1 He has more lately, however, substituted the follow- 
ing operation: 2 The eye having been fixed with a pair of sharp 
forceps at the upper and middle third of the margin of the cornea, 
he enters a pointed knife (a line in width and bent at an angle) in 
the sclero-corneal junction, 1 or 2 lines from the forceps at the 
summit of the cornea, and this, being passed well into the anterior 
chamber, is pushed, with a sawing movement, -along the summit, 
for a distance of 3 iines. If no iridectomy is to be made, the cap- 
sule is now to be opened with the pricker ; otherwise a portion of 
the iris, having been drawn out of the wound, is to be excised, and 
the capsule then lacerated. Finally the section is to be sufficiently 
enlarged with a narrow, blunt-pointed knife, to permit of the ready 
exit of the lens by simple pressure on the lower part of the cornea. 

[Dr. Taylor 3 has lately modified the above method, by excising 
a small portion of the periphery of the iris instead of its whole 
breadth, the pupillary margin and portion of iris attached to it 
being left untouched and free in the anterior chamber ; the lens is 
then extruded through the gap in the ordinary way, gliding behind 
the pupil so that there is no stretching of the sphincter. In this 
way Dr. Taylor believes he has secured all the advantages in the 
way of safety and certainty of an associated iridectomy, and at the 
same time attained the grand desideratum, a central and moveable 
pupil. 

To avoid the disadvantages in Graefe's operation arising out of 
the peripheral position of the wound, and the disadvantages in flap 
extraction arising out of the height of the flap, Dr. Liebreich was 
led to devise a new method of extraction. 4 He found that without 
actual formation of a flap that mechanism can be brought about, 
by means of which the advancing equator of the lens overcomes the 
obstacles of the iris and of the sphincter .pupillse in order to enter 
the wound. Avoiding iridectomy he found he could do without 
elevators and forceps, " and thus change the whole operation into a 
less violent and almost painless one." 

1 " Ophthalmic Review," No. 9. " "R. h. 0. H. Rep ," vi 3, 197. 

3 " The Lancet," Nov. 4, 1871. 

4 St. Thomas's Hospital Reports," New Series, vol. ii. p. 259. 



VON graefe's extraction 289 

The incision is situated entirely within the cornea, with the ex- 
ception of the points of puncture and contra-puncture, which are 
placed about one millimetre beyond it in the sclerotic 1 — the whole 
remaining incision passing with a very slight curve through the 
cornea, so that the centre of it is about 
1J — 2 millimetres within the margin Fig. 111. 

of the cornea (Fig. 111). All the in- 
struments required are two, namely, a 
very small Graefe's knife, and a cysto- 
tome which has a common Daviel's 




spoon at the other end. Supposing Ji|i||p«f T"%g\i W®m 
the right eye is to be operated upon; l|§p ; jv. : ;v ''^^^S^^^^ 
the operator, standing behind the pa- ^^4^f ~" "/ 
tient, takes hold of the upper eyelid ^^KIIP^ 1 

with the index finger of his left hand, 
whilst he slightly presses the middle 

finger against the inner canthus of the eye. The knife, held in the 
right hand with its back horizontal and backwards, the plane of 
the blade making with the horizontal meridian of the eye an angle 
of about 45°, enters the sclerotic at the point indicated. " Without 
altering the direction, the knife passes through the anterior chamber 
in order to make the contra-puncture on the opposite side, so that 
the point of the knife becomes visible in the sclerotic about one 
millimetre (or less) distant from the cornea. The knife is now 
pushed forwards, so that its retraction finishes the incision. As 
soon as the incision is made, the eyelid is to be dropped. 

" The second part of the operation consists in the careful opening 
of the capsule. 

" In the third part Daviel's spoon is slightly pressed against the 
inferior margin of the cornea, and the index finger of the left hand, 
which holds the upper eyelid, through it exerts a very slight pres- 
sure on the highest point of the cornea. Thus the lens is made to 
rotate a little, its lower margin presses in the manner already de- 
scribed against the posterior surface of the iris, pushes the iris 
forward, passes along it to the margin of the pupil, overcomes the 
obstacle and places itself freely in the wound, which is made to 
gape by Daviel's spoon pressing against it. A slight pressing 
movement of the index finger of the left hand, by means of which 
the upper eyelid is shifted from above downwards over the cornea, 
serves to expel the lens. Similar movements of the lids are em- 
ployed for the purpose of forcing out any debris of the cortical sub- 
stance, after pushing them from behind the iris towards the pupil, 
by gently rubbing the shut eyelids. Should the pupil then not 
appear round, but its margin drawn towards the wound, it regains 
its normal position by an outward shifting of the lower lid ; or, if 
that be not sufficient, by the introduction of Daviel's spoon. Im- 

1 Of course only as regards the outside of the wound ; as regards the inside, ail 
the wound, even the puncture, is situated in the cornea, the peripheral part of 
which cannot be reached by a knife introduced in the indicated position without 
previously passing through a small portion of the sclerotic. 
19 



270 DISEASES OF THE CRYSTALLINE LENS. 

If the prolapse is large, and produces a wide gaping of the wound, 
the pain and irritation are often very great. The eye should be 
opened and the real condition ascertained. If protrusion of the 
iris has occurred, the lids must be gently closed again, and a firm 
compress applied, which will not only favor the consolidation of 
the wound by the formation of a layer of lymph over the prolapse, 
hut will prevent its increasing in size ; and by the continuance of 
gentle pressure will even cause it to shrink. Afterwards, when 
the wound is quite consolidated, and a firm layer of exudation 
covers the prolapse, the latter may be pricked with a fine needle, 
as has been recommended by Mr. Bowman, so as to let the aqueous 
humor, which is distending it, flow off. The prolapse then shrinks 
and dwindles down. This pricking may be repeated several times. 
If the prolapse is large and widely distends the section, it may be 
necessary to remove it, either with scissors or with the extraction 
knife, a compress being afterwards applied. Some surgeons touch 
the prolapse with a stick of nitrate of silver, but this often pro- 
duces great irritation. The prolapse may have so drawn up the 
pupil that it is quite covered by the upper lid, or even involved in 
the section, which will afterwards necessitate the formation of an 
artificial pupil, and this will often also cause the prolapse to shrink. 
Prolapse of the iris, occurring after extraction, is not only a source 
of long-continued trouble to the patient, but may even prove very 
dangerous, by setting up protracted inflammatory complications — 
e.g., irido-choroiditis — which may eventually destroy the eye. 

But still more dangerous is the occurrence of suppuration of the 
cornea, which is to be chiefly feared during the first two days. It 
may be diffuse or circumscribed. The former, according to Von 
Graefe, occurs generally in from twelve to twenty-four hours after 
the operation, the latter in from sixteen to thirty-six hours. The 
lids become swollen and red, the eye painful, and there is a more 
or less copious muco-purulent discharge. On opening the eye, we 
may find a considerable degree of chemosis surrounding the cornea. 
If the suppuration is partial, the edges of the wound will show a 
yellow purulent infiltration, which extends deeply into the sub- 
stance of the cornea, the whole of the flap perhaps also becoming 
opaque. The remainder of the cornea, however, retains its trans- 
parency sufficiently to permit our seeing the iris at this point. But 
if the suppuration is diffuse, the infiltration is not confined to 
the line of incision, but extends round the cornea, the whole ex- 
panse of which assumes an opaque yellow tinge. "We must con- 
sider diffuse suppuration as hopeless, for the inflammation generally 
extends to the iris and ciliary body, and in the worst cases general 
inflammation of the eye (panophthalmitis) ensues. If this occurs, 
the inflammatory symptoms become greatly intensified, the pain is 
often excruciating, the lids greatly swollen, the discharge thick, 
purulent, and profuse. We can then only endeavor to alleviate 
the sufferings of the patient by the application of warm sedative 
poultices or fomentations, for all hopes of saving the eye are gone. 
But the partial suppuration of the cornea must also be regarded 



FLA.F EXTRACTION'. 271 

with great anxiety, for it may not only pass over into the diffuse 
form, but it may give rise to suppurative iritis or iridocyclitis, 
which may end in atrophy of the globe. It has been' long a keenly- 
debated question whether the suppuration commences in the iris 
and passes thence to the cornea, or whether it originates in the 
latter, and extends secondarily to the iris and ciliary body. Yon 
Graefe maintains the latter view. According to him, the iritis 
which occurs at this early stage is propagated or secondary, whereas 
that which comes on at a later period is primary or simple iritis. In 
partial suppuration of the cornea we must endeavor if possible to 
prevent its extension, and this can only be done by supporting the 
patient by nutritious diet, bark and ammonia, and stimulants, and 
by the application of a pressure bandage. No other local remedies 
will prove of any avail. Von Graefe first pointed out the advantage 
of the pressure bandage in such cases, and I have myself frequently 
seen it, in his practice, of the greatest benefit in limiting the sup- 
puration of the cornea, and can therefore strongly recommend it. 
In very feeble decrepid individuals it may be alternated with warm 
chamomile or poppy fomentations, which should be applied for an 
hour, at intervals of two or three hours. I know that many sur- 
geons will view the application of a pressure bandage to an eye 
affected with suppuration of the cornea with astonishment and in- 
credulity ; it is, however, certain that it often proves very bene- 
ficial, and tends more than any other remedy to diminish the 
swelling of the lids and the discharge, and to limit the suppuration 
of the cornea. So much care and nicety are required in applying 
the pressure bandage, that the surgeon should always do this 
himself, unless he has an exceptionally trustworthy and dexterous 
nurse. Von Graefe has also called attention to the very important 
fact, that in very old and feeble individuals suppuration of the 
cornea may occur without their having experienced the slightest 
pain or uneasiness in the eye. The surgeon, perhaps, congratulates 
himself upon the apparently excellent progress of the case, and 
then, on opening the eye, finds the cornea suppurated. 

The primary or simple iritis which may occur after the extrac- 
tion, does not generally come on before the fourth or fifth day after 
the operation. It may be due to the bruising or contusion of the 
iris by the instruments, or by the passage of the lens through the 
pupil, or it may be set up by the irritation produced by portions 
of lens substance which have remained behind. The patient ex- 
periences pain in and around the eye ; the lids become swollen, and 
there is more or less photophobia and lachrymation. On opening 
the eye, we may find a considerable amount of chemosis surround- 
ing the cornea, which is clear, but the aqueous humor is somewhat 
clouded, the iris discolored, and the pupil contracted. If the patient 
is sufficiently strong, much benefit is derived from the application 
of leeches to the temples. A strong solution of atropine (four grains 
to the ounce of water) should be frequently applied, so that the 
pupil may be widely dilated. Belladonna ointment should be 
rubbed over the forehead three or four times daily. 



272 DISEASES OF THE CRYSTALLINE LENS. 

If, after flap extraction, the case has throughout progressed favor- 
ably, the patient may be permitted to leave his bed for an hour or 
two at the end of the fifth or sixth day. He should, however, wear 
a light bandage, and the room be somewhat darkened, but it should 
at the same time be kept cool and well ventilated. If the remain- 
ing in bed proves very irksome, which is apt to be the case in 
country people accustomed to an active life, it may be well to per- 
mit the patient to get up even on the third or fourth day. But 
then he must be very carefully watched. In a hospital in which 
there are no special eye wards, the bed should have dark blue cur- 
tains round its head, so as to afford a protection against cold and 
draught, and the bright light of the ward. In such a case, I think 
it also very advisable to keep the patient in bed some days longer 
than would be necessary in a private room or a special ward. At 
the end of the first week, the bandage may generally be exchanged 
for a shade, and the patient be gradually accustomed to the light. 
Should, however, any inflammatory symptoms appear, such as pho- 
tophobia, lachrymation, swelling of the lids, etc., the bandage should 
be reapplied, and increased care be taken of the eye. If the weather 
is favorable, the patient may go out into the air at the end of a 
fortnight. This often proves of great benefit, especially if there is 
any conjunctivitis, which is apt to become chronic if the confinement 
to the house has been long. In such a case a weak astringent col r 
lyrium should be prescribed. 

I have already mentioned that, in certain cases of immature senile 
cataract, in which the progress is extremely slow, and the opacity so 
advanced or situated (e. g., at the posterior pole of the lens) as to 
impair vision considerably, it may be advisable to hasten the pro- 
gress of the cataract by pricking the capsule and admitting the 
aqueous humor to the lens substance. Great care must, however, 
betaken not to divide the capsule too freely, as this may cause con- 
siderable swelling of the lens substance, and give rise to severe iritis 
or iridocyclitis. It is much better to make only a small opening in 
the capsule, and to repeat the operation if necessary, several times, 
more especially if a considerable portion of the lens is still trans- 
parent. If severe inflammation supervenes, and if it does not yield 
rapidly to antiphlogistics, it is advisable, more especially if the ten- 
sion of the eye is increased, to remove the lens at once, either by 
the flap extraction or Von Graefe's operation ; in the former case it 
would be well to make at the same time a large iridectomy. 

Von Graefe 1 has recommended that a downward iridectomy should 
precede the laceration of the capsule. About five or six weeks after- 
wards a superficial crucial incision is made in the capsule with a 
fine needle (the pupil having been previously widely dilated by atro- 
pine). This wide dilatation is to be maintained in order to afford 
plenty of room for the swelling of the lens, and prevent its pressing 

1 " Archiv. f. Ophthalmologic," x. 2, 209; vide also a paper upon this subject by 
Dr. Mannhardt in the " Sitzungsberichts der Ophthalmologischen Gesellschaft," 



FLAP EXTRACTION. 273 

upon the iris and ciliary body. Generally, but very slight irrita- 
tion follows the laceration of the capsule, and flap extraction may 
be performed from about six to twelve days afterwards, when the 
cataract will readily escape. For reasons already stated, I should 
prefer to make the iridectomy upwards. 

I have before mentioned that the chief dangers to be feared after 
flap extraction are suppuration of the cornea, prolapse of the iris, 
and iritis. The principal causes which may produce the latter are 
1. Bruising of the iris by the instruments and by the passage of 
the cajtaract through the pupil, more especially if the latter is some- 
what small and rigid, so that it dilates with difficulty. 2. The 
contusion and irritation which the iris may suffer in the attempts 
to replace a prolapse. 3. The irritation set up by portions of lens 
matter remaining behind the iris or adhering to the pupil, which 
is especially apt to occur if the pupil is small and rigid and the cata- 
ract immature, or if it possesses a small nucleus, with a considerable 
portion of softish cortical substance. Now, in accordance with the 
fact that the segment of the iris corresponding to the corneal sec- 
tion is the portion most exposed to these different influences, we 
find that this almost always forms the starting-point of the inflam- 
mation (iritis). In order to diminish these dangers it has been pro- 
posed to remove this portion of the iris prior to the extraction of 
the cataract — to perform, in fact, a preliminary iridectomy. Yon 
Graefe originally pointed out that such a proceeding might be ad- 
vantageous in some cases, and Dr. Mooren 1 subsequently submitted 
this plan to an extensive trial, with marked success. Mooren makes 
the iridectomy about 2 — 6 weeks before the extraction. But it 
must be admitted that few persons are wiling to undergo two sepa- 
rate operations for the extraction of cataract, except this be abso- 
lutely necessary. To avoid this inconvenience the iridectomy may 
be combined with the operation of flap extraction, as was advised 
by Jacobson, who introduced the following modification of the flap 
extraction. 2 The patient having been placed under chloroform, 
the lower flap extraction is to be performed, the puncture and 
counter-puncture, however, lying about half a line below the hori- 
zontal meridian of the cornea, and not in the substance of the latter, 
but in the sclero-corneal junction, as he believes that union takes 
place more readily here than in the cornea. The lens having been 
removed in the usual manner, he excises the corresponding segment 
of iris, in order to diminish the risk of iritis, prolapse of the iris, 
and suppuration of the cornea. 

I have mentioned that Professor Jacobson places the patient 
thoroughly under the influence of chloroform. Most operators 
(amongst whom I must include myself) have hitherto been afraid 
of giving chloroform in flap extraction, on account of the danger 
of vomiting or retching during or after the operation. The wound 

1 " Die verminderten Gefahren einer Hornhautvereiterung bei der Staarextrac- 
tion," by Dr. Mooren. Hirschwald, Berlin, 1862. 

2 "Ein neue* und gefalirloses Operations — Verfahren zur Heilung des grauen 
Staares," von Dr. Jacobson, Peters., Berlin, 1863. 

18 



274 DISEASES OF THE CRYSTALLINE LENS. 

is so large (embracing nearly half the cornea) that'a fit of vomiting 
or severe retching may cause a great loss of vitreous humor, and 
may even force out the retina and choroid. Professor Jacobson 
states, however, that there is no danger of vomiting if the patient 
he thoroughly narcotized, and Mr. "Windsor, of Manchester, has 
published 1 a series of twenty cases of flap extraction successfully 
performed under chloroform. If chloroform is given in eye opera- 
tions, the patient should be placed thoroughly under its influence ; 
otherwise it is better to abstain altogether from its use. These 
operations, more especially those upon the iris and for cataract, are 
of so delicate a nature, that a sudden start of the patient's head, 
or a fit of vomiting or retching, may not only endanger the result 
of the operation, but even the safety of the eye. When the patient 
is so deeply narcotized, the sudden inhalation of a strong dose of 
chloroform may prove very dangerous ; and it is therefore of great 
importance to know exactly what percentage of chloroform the 
patient is breathing. For this reason I greatly prefer Clover's 
apparatus for administering chloroform. It is not only the safest 
method, but by no other have I uniformly seen such perfect tran- 
quillity and unconsciousness produced, without there being any 
cause, for fear. There is little or no struggling or straining ; the 
patient breathes calmly and quietly ; and when he is thoroughly 
under its influence the most difficult and delicate ophthalmic ope- 
rations may be performed without fear or risk. In order that there 
may be no vomiting or retching, strict orders should be given that 
the patient does not take any food or drink for three or four hours 
prior to the operation. 



5.— EXTRACTION OF THE LENS IN ITS CAPSULE. 

This operation was first practised by Richter and Beer, but fell 
into disuse until it was some years ago reintroduced, amongst 
others by Sperino, Pagenstecher, and Wecker. Dr. Pagenstecher 2 
originally removed the lens in its capsule with much success by 
the lower flap operation (the section lying, however, in the scle- 
rotic), combined with a large iridectomy, the patient being chloro- 
formed. He has favored me with the following description of his 
present mode of operating, for during the last 18 months he has 
adopted Von (Iraefe's upward linear incision, and he has found 
that the delivery of the lens in its capsule is (cceteris paribus) as 
easy as with the flap operation. Indeed, he has observed, that loss 
of vitreous is less frequent, and if it does happen, less copious than 
with the flap incision. In those cases in which the connection 
between the capsule and the suspensory ligament is not sufficiently 
relaxed to permit of the easy extraction of the lens in its capsule 
by slight pressure of the curette on the lower part of the cornea, 
he employs a large, but very shallow, round curette (made by 

1 "Ophthalmic Review," vol. ii. 365. 

2 "Klinische Beobachtungen," Wiesbaden, 1866. 



EXTRACTION OF THE LENS IN ITS CAPSULE. 275 

Messrs. Weiss). This is to be very carefully passed behind the 
equator of the lens 1 and slid downwards along the posterior cap- 
sule, until its free margin embraces the lower circumference of the 
equator of the lens. After a slight rotation, produced by turning 
the handle from the centre towards one angle of the incision, the 
lens is gently drawn upwards, the handle of the curette being at 
the same time somewhat depressed towards the edge of the orbit, 
thus pressing the lens slightly against the cornea and preventing 
its slipping out of the cavity of the curette. Since employing the 
linear incision, he has abandoned the use of chloroform, as there is 
generally a great tendency for the eye to roll upwards during the 
narcosis, which of course renders the manipulation of the curette 
very difficult. The eyeball, even if the curette is used, is to be 
steadily fixed with the forceps, which are to be applied at that 
point of the sclerotic which lies exactly in the same meridian as 
the centre of the linear incision. After having practised the ex- 
traction of the lens in its capsule for a period of five years, Dr. 
Pagenstecher has arrived at the following conclusions as to the 
cases in which it is indicated : 1. He prefers the extraction of the 
lens in its capsule to that with laceration of the latter, in all those 
cases in which it may be presumed that the capsule is firmer than 
its attachment with the zonula of Zinn. This generally occurs in 
cases of over-ripe cataract, both in those which are hard and some- 
what shrunken, and those which are softish or partly fluid (Mor- 
gagnian cataract). 2. It is also very suitable in those cases in 
which the progress of the opacity is extremely slow, and certain 
portions of the lens always remain transparent, so that the cataract 
never becomes perfectly mature. Such cataracts are generally 
small in size, and the capsule is but very slightly attached to the 
zonula. 3. It will, as a rule, be found suitable in those cases of 
cataract which have become developed after irido-choroiditis, and 
iritis with posterior circular synechia. The adhesions between the 
capsule and the iris must of course be detached prior to the ex- 
traction of the cataract, for which purpose a small blunt-pointed 
silver hook is to be employed. 4. It may be recommended where, 
together with the cataract, there is a. tremulous iris ; for it will 
often be found that the latter is caused by a shrinking in the size 
of the lens, or a diminution of the vitreous humor, which should 
generally lead us to suspect atrophy of the zonula. The last two 
categories are, moreover, also suitable for this mode of operation, 
because of the tendency to inflammatory complications of the iris 
which exists in them ; in consequence of which, it is a matter of 
much importance to guard the iris against the irritation produced 
by remnants of cortical substance or portions of capsule. 

Mr. Bowman has also occasionally extracted the lens in its capsule 
by Graefe's operation in cases of over-ripe cataract, in which the 

1 This manoeuvre is facilitated, as Dr. Pagenstecher points out, if a little pressure 
is exerted on the lower portion of the lens, which causes the summit of its equator 
to be tilted forwards, and frequently detaches the zonula from the periphery of 
the lens. 



276 DISEASES OF THE CKYST ALLINE LENS. 

connection between the capsule and the suspensory ligament was 
relaxed. 

"Wecker 1 performs the lower flap operation ; the incision does not, 
however, lie far in the sclerotic, nor does he leave a conjunctival 
bridge standing. A portion of iris having been excised, he passes a 
curette behind the lens and draws it out in its capsule. "When the 
lens has reached the incision, an assistant, grasping its edge with 
a Daviel's curette, extracts it. His results have also been very 
favorable, and he has often succeeded in extracting the lens without 
any loss of vitreous humor. 



6.— LINEAR EXTRACTION. 

Before describing this mode of operating, I will glance for a 
moment at its history. 2 In 1811, Gibson introduced it as supple- 
mentary to the needle operation, in those cases of soft cataract in 
which the lens (after having been divided) was not absorbed with 
the desired rapidity or success. He also employed it in capsular 
and membranaceous cataract. His mode of operating consisted in 
removing the lens through a small corneal section, which was about 
three lines in extent, and was situated about one line from the 
sclerotic. In 1814, Travers, after dividing the capsule, displaced the 
lens in the anterior chamber, and then removed it through a small 
corneal section. He, however, subsequently gave up this method, 
and, making a quarter section of the cornea, divided the capsule 
with the point of the knife, and if the lens was sufficiently soft, 
let it escape through the section, but if it was too firm for this, he 
introduced a curette into the anterior chamber, and by its aid re- 
moved the lens piecemeal. Both the operations of Gibson and 
Travers fell into disuse, until about 1851, when Bowman and Von 
Graefe, quite independently of each other, reintroduced linear ex- 
traction. Von Graefe, having worked out the subject extensively 
and with great care, states in his first essay upon it 3 that the linear 
extraction is especially indicated in the cortical cataract of youthful 
individuals, and also in those cases in which there is so much swell- 
ing up of the lens substance (either in consequence of a needle opera- 
tion, or of some injury to the lens) as to threaten the safety of the 
eye. But he thinks it unsuitable if the lens retains its normal con- 
sistence, and still more so, if there is a hardish nucleus. As a gene- 
ral rule, linear extraction is, therefore, indicated in cases of cortical 
cataract, occuring between the age of ten and thirty, or even thirty- 
five. It is also often employed with advantage as supplementary 
to the needle operation. Linear extraction is to be performed in 
the following manner: The pupil having been previously well 
dilated with atropine, and the patient placed under the influence of 



1 "Maladies des Yeux," 2d edit., p. 225. 

2 For an interesting historical sketch of this operation, I must refer the reader to 
Von Graefe's paper on " Modified Linear Extraction," "Arch. f. Ophthalm.," xi. 3. 

3 " Arch. f. Ophthalm.," i. 2. 



LINEAR EXTRACTION. 277 

chloroform, the eyelids are to be kept apart by Weiss's spring spec- 
ulum, and the eye steadied with a pair of forceps. An incision is 
then to be made in the cornea, at its temporal side, and about one 
line from the sclerotic, with a broad straight iridectomy knife. The 
incision should be about from two to two and a half lines in extent. 
The capsule is then to be divided with the cystotome, and the lens 
removed. In order to facilitate the exit of the cataract, the con- 
vexity of the curette is to be placed against the edge of the cornea, 
which causes the section to gape ; a slight counter-pressure being 
at the same time exerted by the forefinger of the left hand, which 
is to be lightly placed against the inner side of the eyeball. By 
alternately pressing with the curette and the finger, the soft lens 
substance will readily exude through the incision. If portions' 1 of 
cortical substance remain behind the iris, the lid3 are to be closed, 
and the globe lightly rubbed in a circular direction to bring these 
flakes into the pupil or anterior chamber, whence they may be 
readily removed. Or Mr. Bowman's suction-syringe may be em- 
ployed for this purpose. Should the iris protrude through the 
incision it must be gently replaced, but if it has been much bruised 
by the exit of the lens or the movements of the curette, it will be 
wiser to excise a portion of it. A light compress bandage is to be 
applied after the operation, and the pupil should be kept well 
dilated with atropine. 

Von Grraefe found that, although occasionally a cataract possessing 
a firm nucleus may be removed through a linear incision without 
danger, this operation is, as a rule, inapplicable when the nucleus is 
hard, for the iris must then be more or less bruised by the passage 
of the lens through the narrow section. The scoop may also have 
to be introduced into the anterior chamber behind the lens, so as to 
facilitate its removal, and this, of course, adds to the contusion of 
the iris. Great irritation of the latter is likewise often produced 
by portions of hardish lens substance remaining behind the iris or 
in the pupil. Now, as the segment of the iris which corresponds 
to the incision is the most exposed to bruising, and interferes the 
most with the ready use of the scoop, we find that this is almost 
always the starting point of any subsequent iritis. In those cases 
in which there was a somewhat firm nucleus, Von G-raefe was 
therefore led to modify the linear extraction, and to excise a por- 
tion of iris prior to the laceration of the capsule, and then to re- 
move the lens with a broad flat scoop. 1 The stages of this operation 
were as follows: 1. The incision was made at the edge of the 
cornea (temporal side), and embraced about a quarter of its circum- 
ference. 2. A portion of iris was removed, the size of which did 
not, however, quite equal the extent of the incision. 3. The cap- 
sule was freely divided quite up to the margin of the lens. 4. A 
scoop was then introduced at the free edge of the lens and gently 
inserted between the posterior cortical substance and the nucleus, 
and the cataract lifted into the anterior chamber and extracted. 

1 "Arohiv. f. Ophthalin.," v. 1. 



278 DISEASES OF THE CRYSTALLINE LE-NS. 

The scoop which he employed for this purpose was shallower, 
broader, and sharper at the extremity than Daviel's curette. Thus 
originated the " modified linear" or " scoop" extraction — an opera- 
tion which afterwards assumed so important a position in ophthal- 
mic surgery. By this modification Von Graefe greatly extended 
the applicability of the linear extraction, for he was now able to 
remove through a linear incision cataracts whose cortex was of' a 
pulpy consistence, and the nucleus moderately large and hard ; a 
form of cataract which would otherwise have necessitated the flap 
extraction. I would here remark that to Von Graefe belongs the 
credit of having first suggested, in some cases, the combination of 
an iridectomy with flap extraction, and also of having introduced 
the modified linear or scoop extraction. The principle of the latter 
operation is essentially his, whatever changes may be made in the 
shape of the scoop, and it is worthy of remark that the latest ope- 
rations assimilate it more to that originally used by him. Mr. 
Critchett has already pointed out these facts in his admirable paper 
upon scoop extraction, 1 in which he says: "Thus there suddenly 
appeared three new methods of operating for cataract, bearing the 
name of their several champions — the method of Mooren, Jacobson, 
and that of Schuft (Waldau) ; but justice compels me to state that 
these gentlemen lighted their tapers at the torch of their great 
master Professor Von Graefe. Each of these methods had been 
previously suggested and practised by him, but only in exceptional 
cases, instead of as a general rule." 

Waldau shortly afterwards contrived a different form of scoop, 
of varying size, which was deeper, broader, and flatter at the 
bottom than Von Graefe's. Its edges were, moreover, high and 
thin, so as to bite into the lens, the anterior lip being the highest, 
and thus facilitating the removal of the cataract by pressing after 
it. By its aid he proposed to remove even the hard senile cataract. 
It was soon found, however, that this form of scoop was too large 
and cumbersome, and its edges too high and sharp, and that it was 
therefore difficult to introduce it readily behind the lens, more 
especially in hard senile cataract, in which it may very easily 
cause displacement of the lens or rupture of the hyaloid membrane. 
Mr. Bowman and Mr. Critchett have since devised some forms of 
scoop which are far better and in all cases preferable to "Waldau's. 
The scoop operation, as performed at Moorfields, has proved re- 
markably successful in the hands of some of our English ophthal- 
mic surgeons, more especially in those of Messrs. Bowman and 
Critchett, who have worked out the subject most thoroughly, and 
have done the most to bring this operation to perfection. As my 
description of it must be necessarily brief, I would refer the reader 
to their admirable articles upon this subject in the " B,oyal London 
Ophthalmic Hospital Reports," vol. iv. p. 4. 

Dr. Adolph "Weber has lately introduced a mode of extracting 
hard cataracts through a linear incision made with a lance-shaped 

1 "Royal London Ophthalmic Hospital Reports," iv. 319. 



LINEAR EXTRACTION. 279 

knife, without any excision of the iris or the employment of a 
traction instrument. He speaks in the highest terms of its success 
in 103 cases in which he has performed it, and some other opera- 
tors are also very warm in its praise. Dr. Weber has favored me 
with the following outline of his present mode of operating ; for a 
fuller description of his operation I must refer the reader to his 
valuable and very interesting article in " Graefe's Archiv." 1 He 
employs a large lance-shaped knife 2 (Fig. 103), which is 10.25 mm. 

Fig. 103. 



in length, and is 10 mm. broad at a distance of 6.5 mm. from its 
point ; and this width it retains for a distance of 2 mm. in order 
that the internal and external wound may be of exactly the same 
size ; thence it becomes narrower to pass over into the stem. The 
back of the blade is not flat, but hollowed out (Fig. 103 c). The 
blade is bent at an angle of about 120°, in order that it may be 
readily used from above or the nasal side. The pupil should be 
kept widely dilated with atropine for a day or two before the ope- 
ration. The eyeball having been steadily fixed below the centre 
of the lower margin of the cornea with a pair of broad fixing for- 
ceps, and gently drawn down, the point of the knife is to be entered 
in the centre of the upper margin of the cornea, just in the sclero- 
corneal junction ; if the diameter of the cornea is less than 12 mm., 
the incision is to lie a little further away from the edge of the 
cornea. The blade is to be carried slowly and steadily forwards 
across the anterior chamber as far as the base of the instrument ; 
its point will then have nearly reached the opposite (lower) margin* 
of the cornea. The knife is then to be very slowly withdrawn. This 
will prevent the sudden escape of the aqueous humor, which, from 
its stimulating the constrictor pupillse, would cause the pupil to 
contract. Moreover, during the slow and gradual withdrawal of 
the knife we can press the back of the blade somewhat against the 
edge of the section, and thus prevent prolapse of the iris. The 
capsule is then to be very freely lacerated, for which purpose 
"Weber uses a very minute double hook, the stem being bent at an 
angle, so as to permit of its being readily turned. The capsule is 
to be divided in the following way, the lines of incision lying some- 
what beneath the iris, as shown in Fig. 104, where the dotted line 
indicates the pupil. The hook having been passed down to a, Fig. 

1 "A. f. O.," xiii. 187. 

' When the cataract is not very large and hard, Weber uses a somewhat smaller 
knife, which is however constructed on the same principle. 




280 DISEASES OF THE CRYSTALLINE LENS. 

104, the capsule is to be divided from a to b, and thence 
to c ; then the instrument is to be again passed to a, 
and the capsule divided from a to d, and thence to c, 
the last incision lying, of course, along the inner margin 
of the section. If, on the withdrawal of the hook, the 
capsule does not present in the section, the instrument 
is to be reintroduced, passed down to e, and the square, 
torn portion of capsule drawn out in the direction of f ; 
or it may be extracted with a small pair of iridectomy forceps. 
The anterior thin lip of a peculiarly constructed curette is then to 
be placed on the external lip of the wound, so as to press this back 
a little, and thus facilitate the presentation of the equator of the 
lens in the incision, the exit of the cataract being assisted by a 
slight simultaneous pressure of the fixing forceps below the cornea. 
During the exit of the lens, the iris generally protrudes a little 
into the wound, and if it does not retract at once when the cataract 
has escaped, it should be replaced by applying Graefe's vulcanite 
curette, and gently moving this from the angles towards the centre 
of the section. This will soon cause the iris to retract, and the 
pupil to resume its normal position, a point which should be always 
carefully attended to before the operation is considered as finished. 



t.— SCOOP EXTRACTION. 1 

Prior to this operation the pupil should be widely dilated with 
atropine, and the cataract examined with the oblique illumination, 
so that the size and hardness of the nucleus, and the consistence of 
the cortical substance, may be ascertained. For the size of the 
incision should be apportioned to that of the nucleus, and to the 
extent and consistence of the cortical substance. The patient 
should be placed thoroughly under the influence of chloroform, for 
any sudden start may endanger the safety of the eye, more espe- 
cially during the period of the introduction of the scoop. The 
incision is to be made in the upward direction with a broad lance- 
shaped knife in the sclero corneal junction, and should average 
from 4 to 4J lines in extent. A corresponding portion of the iris 
having been removed, the capsule is to be freely divided with the 
pricker. The next and most difficult step of the operation is the 
removal of the lens with the scoop, for which purpose either Mr. 
Critchett's (Fig. 10.5) or one of Mr. Bowman's (Figs. 106 and 107) 
scoops may be employed. The eye having been fixed with the 
forceps, the scoop is to be introduced into the section, being turned 
directly towards the back of the eye, so that its anterior lip may 
glide past the free upper margin of the lens exposed by the iri- 
dectomy. When the edge of the scoop has passed the margin of 
the lens, it is to be turned quite flat, and slowly and gently insinu- 

1 For a full description of this operation, Tide the valuable articles by Mr. Crit- 
cliett and Mr. Bowman, "R. L. O. H. Rep.," iv. 4. pp. 316 and 332. 



VON graefe's extraction. 



281 



ated with a delicate, somewhat wriggling movement into the pos- 
terior cortical substance between the capsule and the nucleus, until 
its further end has passed the margin of the latter. When the 



Fig. 105. 



Fig. 106. 



Fig. 107. 



lens is well grasped by the scoop, it should be slowly removed, care 
being taken that its anterior surface is not pressed too much forward, 
otherwise it will bruise the iris and cornea. 



8— VON GRAEFE'S MODIFIED LINEAR EXTRACTION. 

Von G-raefe has lately devised a very important modification of 
the linear extraction, which combines the advantages of the flap 
with the scoop extraction. For whilst the section lies almost 
entirely in the sclero-corneal junction, it yet, on account of its 
shape and mode of formation, gapes sufficiently to permit the 
ready exit of even a hard senile cataract without the aid of any 
traction instrument. The success of this operation has been so 
great that most ophthalmologists, amongst whom I may mention 
Mr. Bowman, have entirely abandoned the scoop extraction, and 
even to a great extent the flap operation. My own experience of 
it has also been extremely favorable, and I prefer it greatly to 
every other mode of extraction for senile cataract. 

The operation is divided into four periods : 1. The incision ; 2. 
The iridectomy ; 3. The laceration of the capsule ; i. The removal of 
the lens. 

1. The patient having been placed under the influence of chloro- 
form, the eyelids are to be kept apart with the stop-speculum and 
the eye fixed and gently drawn down with a pair of forceps, which 
are to be applied close beneath the centre of the cornea. For this 
operation I prefer Dr. Noyes's (of New York) speculum, the rack 
and screw of which are on the nasal side, thus leaving the temporal 
side of the eye quite free for the manipulation of theknife in form- 
ing the section. Another advantage of this form of speculum is, 
that it does not press upon the eyeball but lifts the lids away from 
it. One and the same speculum does not, however, suit both eyes, 
but it must be made right and left. The same is the case with 
Weiss's stop-speculum, for the knob of the screw should always be 
on the lower branch (if the upper section is made), for if it is on 
the upper branch its projection will considerably incommode the 



282 DISEASES OF THE CRYSTALLINE LENS. 

operator during the making of the incision. If it is found during 
any part of the operation that the patient is straining a good deal 
and that the speculum is pressing on the globe, an assistant should 
be directed to lift it forward a little away from the eyeball, and 
keep it thus until the operation is completed. 

The point of a long narrow knife 1 (Fig. 108), with its cutting 
edge upwards, is then to be entered in the sclerotic near the upper 
and outer portion of the cornea (at the point A, Fig. 109, which 
represents the left cornea), about one-third of a line from its edge, 
so that it may enter the anterior chamber quite at the periphery. 

Fig. 108. Fig. 109. 




The point of the knife should be at first directed downwards and 
inwards towards c, so as to enlarge the inner incision, and then, 
when the blade has advanced about 3J lines into the anterior 
chamber, the handle is to be depressed and the point carried up 
and along to B, where the counter-puncture is to be made, at a 
point lying opposite to that of the puncture (A). Great care must 
be taken that the counter-puncture does not lie too far in the 
sclerotic, which may easily occur if the presentation of the point 
of the knife is not carefully watched, or the blade is passed too far 
downwards and inwards before it is turned upwards to make the 
counter-puncture. 

Such an error will give rise to a wide gaping wound, and in all 
probability, if the patient strains at all or the speculum presses on 
the globe, to great loss of vitreous, even perhaps before the iris has 
been excised, and almost with certainty during the pressure which 
has to be made on the eyeball to facilitate the escape of the lens. 
In order to avoid any irregularity in the height of the corneal 
flap (Lappenhohe), Graefe recommends that when the point of the 
knife is carried downwards and inwards (towards c, Fig. 109), 
through the anterior chamber, its edge should not be kept quite 
parallel to the iris, but turned a little forward. By so doing, we 
give to the temporal portion of the wound a more horizontal 
direction, so that it lies in almost the exact continuation of the 
remainder of the section. 

As soon as the counter-puncture has been made, the edge of the 
blade is to be turned somewhat obliquely upwards and forwards, 

1 The knife should be very narrow. Gradually some instrument-makers have 
departed more and more from the original model, and have made it much too 
broad. Von Graefe lays great stress upon the advantages of having the instru- 
ment very narrow, as its manipulation at the extreme periphery of the anterior 
chamber is much more easy, and the facility of turning it much greater than when 
the blade is broad. 




VON graefe's extraction. 283 

and the knife pushed straight on until its length is nearly ex- 
hausted, when the section is to be finished by drawing it slowly 
and gently backwards from heel to point. [In Fig. 
110, the section is represented by the uppermost [Fig. 110.] 
undotted line.] The knife will now be beneath th6 
conjunctiva, which is next to be divided in such a 
manner as to leave a conjunctival flap of from 1 to 
1J line in height. In order that it may not exceed 
this extent, the edge of the blade must be turned 
horizontally forwards or even downwards. If the cataract is hard 
and the nucleus very large, it is advisable to make the points of 
puncture and counter-puncture about J of a line lower, so as to 
obtain a somewhat larger section. Directly the counter-puncture 
is made, the aqueous humor escapes beneath the conjunctiva and 
bulges this out, giving rise to a considerable thrombus, which 
somewhat hides the exact point of counter-puncture and the line 
of section. This is often very embarrassing to the young operator, 
and apt to mislead him as to the true course of the section he is 
making. 

By this incision the track of the wound lies almost perpendicular 
to the surface of the cornea, and is more steep (less slanting) than 
that made by the lance-shaped iridectomy knife. Thus the exit of 
the lens is much facilitated, for its equator passes more readily into 
the track of the wound, and the cortical substance also exudes more 
easily. There is, however, the disadvantage that if the section is 
made too steep the suspensory ligament loses its support, and hence 
there is a greater tendency to loss of vitreous humor than if the 
incision is made with the lance-shaped knife. Von Graefe 1 does 
not now give the knife so steep a direction in making, the section 
as originally, but turns its edge somewhat more obliquely upwards 
and forwards ; in this way the external wound lies throughout in 
the sclero-corneal junction, the conjunctival flap is more easily 
formed, and the section gapes less than if it be made more steeply. 
If the cataract has a big, firm nucleus, care must be taken that 
the incision is sufiiciently large to permit of the ready exit of the 
lens without the necessity of employing much pressure upon the 
eye, or the use of a scoop. In such cases I always make the punc- 
ture and counter-puncture somewhat lower down, and a little nearer 
the horizontal diameter of the cornea, which is, I think, to be pre- 
ferred to a more peripheral position of the section. For a large 
hard cataract the incision should measure about 5 lines ; but if the 
cataract, though perfectly hard, is somewhat flattened, one of about 
4f lines will suffice. This will permit of the easy exit of the cata- 
ract, a very gentle pressure with a curette upon the lower portion 
of the cornea sufficing to " coax" it out. If it is found, however, 
during the fourth stage that the section is a little too small, it is 
better to enlarge it somewhat at each angle with a pair of blunt- 
pointed scissors, than to endeavor to force out the lens by an extra 

1 "A. f. 0.," xiii., 2, p. 559, and "A. f. O.," xiv., 3, 109. 



284: DISEASES OF THE CRYSTALLINE LENS. 

degree of pressure on the cornea, as this will he almost sure to 
cause rupture of the hyaloid, and an escape of the vitreous humor 
perhaps even before the exit of the lens, in which case we shall be 
obliged to pass in a scoop behind the cataract and thus remove it. 

Mr. Critchett prefers to make the section throughout in the 
cornea, quite close to its edge, as he thinks that this diminishes the 
chance of loss of vitreous and of prolapse of the iris. He also 
makes but a small iridectomy! 

2. The iridectomy. — If the section does not come well into view, 
but is somewhat hidden by the upper lid, an assistant is to draw 
the eye gently down with a pair of forceps, taking great care not 
to press upon or drag down the eyeball. The operator should then 
turn down the little conjunctival flap over the cornea with a pair 
of very small iris forceps, for thus the prolapsed portion of the iris 
will be laid quite bare ; the iris should then, if necessary, be drawn 
forth a little more and excised to the required extent quite close to 
its ciliary insertion. This is not, however, to be done by one cut, 
but by 3 — 4 successive snips, the scissors being slightly turned so 
as to follow the curvature of the eyeball, which allows of the blades 
being applied quite close to the section, or even perhaps a little 
between its lips. As it is particularly at the angles of the wound 
that little portions of iris are apt to remain involved in the section, 
special attention should always be directed to these situations, and 
any little protrusion be snipped carefully off. For if little portions 
of iris remain in the incision, they may retard the firm union of 
the section, be productive of much irritation, and give rise to a 
cystoid cicatrix, or to a more or less considerable prolapse of the iris, 
which may not only prove very troublesome by keeping up a long 
continued state of irritation, but even dangerous to the eye, by 
giving rise to inflammatory complications, such as iritis serosa. 
Another point to which Von G-raefe calls particular attention 1 is 
the position of the cut angles of the sphincter pupillse after the ex- 
cision of the iris, and he always looks, before he passes on to the 
laceration of the capsule, whether or not the sphincter has retracted 
to its proper position. If one or both angles of the sphincter are 
displaced upwards or involved in the section, the convex surface of 
the vulcanite curette should be placed on the cornea close to the 
angle of the wound towards which the pupil is displaced, and then 
gently passed from the periphery towards the centre of the cornea; 
this will not only tend to push the iris down, but will also stimu- 
late the action of the constrictor pupillae, and thus assist in causing 
the retraction of the angle of the sphincter. If only the nasal angle 
of the latter is involved, we may push this gently down and smooth 
the iris with the back of the cy3totome before we proceed to lace- 
rate the capsule. 

The extent of the iridectomy must vary somewhat according to 
the size and hardness of the nucleus, and also according to the po- 
sition of the upper lid. If the nucleus is large and hard, I think 

1 "A. f. O.," xiv., 3, 136. 



von graefe's extraction. 285 

it better to remove a considerable portion of iris, even perhaps 
almost corresponding to the size of the incision. For this will 
permit of the ready exit of even a large hard cataract, without any 
bruising of the iris. Moreover, if the upper lid hangs down suffi- 
ciently to cover the upper third of the cornea, no unsightliness or 
inconvenience will be produced by so wide an iridectomy. But 
it will be different if the palpebral aperture is wide, so that the 
whole cornea is exposed, for then the large artificial pupil may 
give rise to a considerable and annoying sensation of glare, and 
also diminish the acuity of vision by producing circles of diffusion 
upon the retina, on account of the irregular refraction at this por- 
tion of the periphery of the cornea. 

3. Laceration of the capsule. — The operator, steadily fixing the 
eyeball with the forceps, next freely divides the capsule with the 
pricker or Von Graefe's cystotome by three successive incisions. 
The one is to commence at the lower edge of the pupil, or even a 
little below it beneath the iris, and extend upwards along its inner 
side, the other passing to the same extent along the outer margin 
of the pupil. Both incisions should reach quite up to the periphery 
of the lens exposed by the iridectomy. An expert operator may 
even carry the incision beneath the iris nearer the periphery of the 
capsule, so as to obtain a very free laceration of the latter. But this 
requires considerable dexterity and delicacy of manipulation, other- 
wise the pricker may easily bruise the iris, or press so much upon 
the lens as to displace it. If there are slight adhesions between 
the iris and the capsule, they should be divided by passing the 
instrument a little beneath the edge of the pupil. Finally, the 
capsule should be lacerated at its periphery in a line correspond- 
ing to that of the incision. In using the pricker, its edge should 
always be turned in a slanting direction, and not be pressed firmly 
backwards, otherwise the cataract may be dislocated into the vitre- 
ous humor, or its upper margin displaced behind the upper edge of 
the incision. 

4. Removal of the lens. — During the earlier period of performing 
his new operation, Von Graefe was in the habit of assisting the exit 
of the lens by pressing upon the upper portion of the sclerotic with 
a broad curette, and aiding this by a counter-pressure with the for- 
ceps below the cornea. When the edge of the lens had once pre- 
sented itself in the section, its delivery was still more assisted by 
gliding the curette in a lateral direction along the sclerotic to the 
angles of the incision (this was termed the Schlitten-manceuvre). It 
was found, however, that the removal of the lens was often difficult, 
without exerting a dangerous degree of pressure, and that, occa- 
sionally, it was necessary, in order to extract the lens, to pass in a 
scoop, or a peculiarly shaped hook devised by Von Graefe. 

He has now, however, substituted for this manoeuvre the use of a 
vulcanite curette, which he presses against the lower portion of the 
cornea, and thus aids the removal of the cataract. It is to be used 
in the following manner : The eye is to be fixed with the forceps, 
which are not to be placed directly below the cornea, as they would 



286 DISEASES OF THE CRYSTALLINE LENS. 

then interfere somewhat with the manipulation of the curette, but 
slightly to the inner or outer side of the centre. The curette is 
then to be placed upon the lower margin of the cornea, and pressed 
slightly backwards and upwards, so as to cause the upper edge of 
the lens to present itself in the section ; and then the pressure is to 
be made directly backwards, in order that the lens may be rotated 
round its transverse axis and tilted well forward into the wound. 
"When this has occurred, its exit is to be gently aided by pushing 
the curette slowly upwards over the surface of the cornea, so that 
it follows step by step the delivery of the lens. If the upper mar- 
gin of the lens does not present in the section, but shows a tendency 
to get behind its upper edge, the latter should be gently pressed 
back with the edge of a curette by an assistant, which will gene- 
rally cause the lens to enter the incision ; or the operator may do 
this himself, and exert the counter-pressure just beneath the cornea 
with the forceps. Or again, the lens may be gently pushed back a 
little with the pricker, until its upper margin again lies opposite the 
incision. If it is found that portions of the lower cortical sub- 
stance are stripped off and are inclined to lag behind, the curette 
should be drawn a little back again, and the fragments of cortex 
pushed along after the body of the lens, and in this way the whole 
cataract may generally be removed. If the appearance of the cata- 
ract indicates the presence of a good deal of soft matter, it is well 
to work this gently towards the centre, by pressing the curette 
lightly from the lower and lateral margin of the cornea towards its 
centre, before attempting to remove the lens, for thus we may often 
succeed in getting the soft matter to exude, together with the 
firmer nuclear portions. If small fragments of lens matter still 
linger behind after the body of the cataract has been removed, they 
should be coaxed out by again passing the curette over the cornea, 
and pushing them in front of the instrument. Or as Von Graefe 
advises, the lid-holder having been removed, the operator should 
gently rub the lids, more especially the lower one, in a circular 
direction, and thus loosen the marginal portions of cortex from 
behind the iris, and bring them into the area of the pupil, and thence 
out through the wound. Von Oraefe attaches great importance to 
the removal of remnants of cortical substance, and often devotes 
some length of time to this purpose. 

The object of making the curette of vulcanite instead of silver 
is that it is more resilient, and the degree of pressure can therefore 
be regulated with the greatest nicety, and its touch is moreover 
more agreeable to the cornea. The vulcanite has, however, the 
disadvantage of being very brittle, so that it breaks very readily. 
For this reason I have lately preferred Weiss's tortoise-shell curette, 
which offers all the advantages of the vulcanite, without its brittle- 
ness. 

The loss of vitreous humor has diminished very considerably since 
Von Graefe substituted the latter mode of removing the lens (by 
pressing from below) for the " Schlitten-manceuvre," indeed in the 
last 230 operations he has only lost vitreous humor in nine cases, 



VON gbaefe's extraction. 2S7 

which gives less than 4 per cent. 1 In three of these the vitreous 
humor was, moreover, fluid. If this occurs, the vitreous may escape 
directly the section is finished, and even before it is attempted to 
excise a portion of iris. In such a case it is best to excise a portion 
of iris, if this can be done without a very great loss of vitreous, 
and then to remove the lens in its capsule by passing Critchett's 
scoop behind it into the vitreous humor, and lifting it out. A con- 
siderable quantity of vitreous will of course escape, but any subse- 
quent inflammation is likely to be far less severe if the entire lens 
is removed in its capsule, than if more or less considerable fragments 
of lens substance and capsule remain behind. 

Several of the best operators still differ in opinion as to the ad- 
vantage of making the section in the sclerotic or in the cornea; for 
whilst Graef'e prefers the former, Critchett and Arlt are in favor 
of the latter proceeding. I think that the exact line and extent of 
the incision should vary with the size and hardness of the nucleus, 
and the dimensions of the cornea. If the nucleus is large and firm, 
and the diameter of the cornea small, the section should be made 
slightly more in the sclerotic, the puncture and counter-puncture 
being also somewhat lower, for we shall thus gain a larger section, 
and the delivery of the lens will be easy, and free from all squeezing 
and bruising of the parts. If the section is made in the cornea, 
and more especially if a portion of cornea is left standing at the 
top, the exit of the lens is often difficult and labored, and accom- 
panied by a good deal of bruising of the parts and stripping oft' of 
the surface matter of the lens, which, if it remains behind, may set 
up very considerable irritation. Moreover, the upper edge of the 
lens may be caught behind the portion of the cornea which has 
been left standing, and be firmly wedged in between it, or the lens 
may even be displaced upwards behind the sclerotic. This is the 
more apt to occur if the first pressure, which is made with the 
curette upon the lower portion of the cornea, is not made backwards 
and upwards, but only upwards, for then the lens will be pushed 
directly upwards, and may become lodged behind the upper portion 
of the cornea. The object of the backward pressure upon the lower 
portion of the lens is to tilt its upper edge into the section, for 
when it has once gained this position the escape of the lens is easy 
enough, provided the section be of a sufficient size. My own ex- 
perience, I must admit, is greatly in favor of the sclerotic section 
lying in the sclero-corneal junction, or very slightly beyond it. 
But where a considerable section is required, I prefer to obtain this 
rather by making the puncture and counter-puncture lower, than 
by making the incision .more in the sclerotic, for in the latter case 
there is always a greater risk of loss of vitreous. 

The after-treatment of this operation is generally extremely 
simple. Liebreich's bandage should be applied directly after the 
operation, and if any severe pain should arise in the course of the 
day, cold water dressing (frequently changed) should be applied, 

1 "A. f. 0.,"xiii. 2, 556. 



288 DISEASES OF THE CRYSTALLINE LENS. 

care being taken that it is not persisted in too long. If the pain 
does not yield to this treatment, a leech or two should be applied 
to the temple. On the second day atropine drops should be pre- 
scribed. The patient may generally leave his bed on the second or 
third day, but this will depend upon individual circumstances, and 
upon the fact as to whether he can have proper supervision. With 
some patients it is advisable to permit their leaving the bed even 
the day after the operation, but it is always wiser to err on the 
side of safety. The general rules laid down for the after-treatment 
of nap-extraction also apply to Von G-raefe's operation. 

Dr. Taylor, of Nottingham, has operated by a method somewhat 
similar to that of Von Graefe (but quite independently of him) since 
the summer of 1865, indeed both appear to have begun about the 
same time. 1 He has more lately, however, substituted the follow- 
.ing operation: 2 The eye having been fixed with a pair of sharp 
forceps at the upper and middle third of the margin of the cornea, 
he enters a pointed knife (a line in width and bent at an angle) in 
the sclero-corneal junction, 1 or 2 lines from the forceps at the 
summit of the cornea, and this, being passed well into the anterior 
chamber, is pushed, with a sawing movement, -along the summit, 
for a distance of 3 lines. If no iridectomy is to be made, the cap- 
sule is now to be opened with the pricker ; otherwise a portion of 
the iris, having been drawn out of the wound, is to be excised, and 
the capsule then lacerated. Finally the section is to be sufficiently 
enlarged with a narrow, blunt-pointed knife, to permit of the ready 
exit of the lens by simple pressure on the lower part of the cornea. 

[Dr. Taylor 3 has lately modified the above method, by excising 
a small portion of the periphery of the iris instead of its whole 
breadth, the pupillary margin and portion of iris attached to it 
being left untouched and free in the anterior chamber ; the lens is 
then extruded through the gap in the ordinary way, gliding behind 
the pupil so that there is no stretching of the sphincter. In this 
way Dr. Taylor believes he has secured all the advantages in the 
way of safety and certainty of an associated iridectomy, and at the 
same time attained the grand desideratum, a central and moveable 
pupil. 

To avoid the disadvantages in G-raefe's operation arising out of 
the peripheral position of the wound, and the disadvantages in flap 
extraction arising out of the height of the flap, Dr. Liebreich was 
led to devise a new method of extraction. 4 He found that without 
actual formation of a flap that mechanism can be brought about, 
by means of which the advancing equator of the lens overcomes the 
obstacles of the iris and of the sphincter .pupillse in order to enter 
the wound. Avoiding iridectomy he found he could do without 
elevators and forceps, " and thus change the whole operation into a 
less violent and almost painless one." 

i " Ophthalmic Review," No. 9. 2 « r. L- q. H. Rep.," vi. 3, 197. 

3 "The Lancet," Nov. 4, 1871. 

4 St. Thomas's Hospital Reports," New Series, vol. ii. p. 259. 




VON graefe's extraction 289 

The incision is situated entirely within the cornea, with the ex- 
ception of the points of puncture and contra-puncture, which are 
placed about one millimetre beyond it in the sclerotic 1 — the whole 
remaining incision passing with a very slight curve through the 
cornea, so that the centre of it is about 
1£ — 2 millimetres within the margin Fig. ill. 

of the cornea (Fig. 111). All the in- 
struments required are two, namely, a 
very small Graefe's knife, and a cysto- 
tome which has a common Daviel's 
spoon at the other end. Supposing 
the right eye is to be operated upon ; 
the operator, standing behind the pa- 
tient, takes hold of the upper eyelid 
with the index finger of his left hand, 
whilst he slightly presses the middle 

finger against the inner canthus of the eye. The knife, held in the 
right hand with its back horizontal and backwards, the plane of 
the blade making with the horizontal meridian of the eye an angle 
of about 45°, enter* the sclerotic at the point indicated. " Without 
altering the direction, the knife passes through the anterior chamber 
in order to make the contra-puncture on the opposite side, so that 
the point of the knife becomes visible in the sclerotic about one 
millimetre (or less) distant from the cornea. The knife is now 
pushed forwards, so that its retraction finishes the incision. As 
soon as the incision is made, the eyelid is to be dropped. 

" The second part of the operation consists in the careful opening 
of the capsule. 

" In the third part Daviel's spoon is slightly pressed against the 
inferior margin of the cornea, and the index finger of the left hand, 
which holds the upper eyelid, through it exerts a very slight pres- 
sure on the highest point of the cornea. Thus the lens is made to 
rotate a little, its lower margin presses in the manner already de- 
scribed against the posterior surface of the iris, pushes the iris 
forward, passes along it to the margin of the pupil, overcomes the 
obstacle and places itself freely in the wound, which is made to 
gape by Daviel's spoon pressing against it. A slight pressing 
movement of the index finger of the left hand, by means of which 
the upper eyelid is shifted from above downwards over the cornea, 
serves to expel the lens. Similar movements of the lids are em- 
ployed for the purpose of forcing out any debris of the cortical sub- 
stance, after pushing them from behind the iris towards the pupil, 
by gently rubbing the shut eyelids. Should the pupil then not 
appear round, but its margin drawn towards the wound, it regains 
its normal position by an outward shifting of the lower lid ; or, if 
that be not sufficient, by the introduction of Daviel's spoon. Im- 

1 Of course only as regards the outside of the wound ; as regards the inside, all 
the wound, even the puncture, is situated in the cornea, the peripheral part of 
which cannot be reached by a knife introduced in the indicated position without 
previously passing through a small portion of the sclerotic. 
19 



290 DISEASES OF THE CRYSTALLINE LENS. 

mediately afterwards I put some atropia into the eye, and close it 
by my compressive bandage." 

This operation is well adapted, Dr. Liebreich says, for the dif- 
ferent cataracts, with the exception of — "1. Those lamineller cata- 
racts, which need only be treated by iridectomy. 2. Cataracts 
which in earliest childhood have to be operated upon by repeated 
division. 3. Perfectly liquid cataracts (division with a broad 
needle). 4. Partial cataracts, without a nucleus, already absorbed 
to a great extent, and therefore chiefly traumatic cataracts, for 
which also division suffices."] 

I will now briefly mention the principal arguments which may 
be advanced in favor of, or against, the different operations for 
senile cataract. In doing this, I shall confine myself to the flap 
extraction, the scoop operation, and Von Graefe's new modified 
linear extraction. 

There cannot be any doubt that the common flap extraction is 
the most perfect operation of all, when it turns out perfectly suc- 
cessful. It is nearly free from pain ; it does not in the least inter- 
fere with the appearance of the eye ; the pupil remains central and 
moveable ; the sight is perfect, and is not at all deteriorated and 
confused by circles of diffusion upon the retina, which are always 
more or less present when an iridectomy has been performed. It 
must, however, be confessed that these great advantages are often 
more than counter-balanced by the considerable dangers which 
beset the operation. On account of the great size of the flap, there 
is much risk of the vitality of the cornea becoming impaired, and 
of its undergoing partial or even diffuse suppuration, which may 
be accompanied by suppurative iritis or irido-choroiditis. Again, 
prolapse of the iris is a not unfrequent complication, proving a 
source not only of great annoyance and irritation, but even of 
danger to the eye. The after-treatment also demands much care 
and attention — more, indeed, than can generally be bestowed in an 
hospital, especially in a general one, with no special nurses or oph- 
thalmic wards. JSTow, in the scoop extraction, these two principal 
dangers — suppuration of the cornea and prolapse of the iris — are 
nearly completely eliminated. On account of the position and shape 
of the incision, suppuration of the cornea, even of limited extent, is 
rare, and a prolapse of the iris can only be slight, and is confined to 
the angles of the section. Moreover, chloroform may be ad- 
ministered without any fear. But it must be admitted that iritis, 
chronic and insidious irido-choroiditis, inflammation of the intra- 
capsular cells, and secondary cataract are more common than in 
flap extraction. Von Graefe's operation, however, offers all the 
advantages of the scoop extraction, viz., the administration of chlo- 
roform, the linear shape of the incision, involving but a small por- 
tion of the cornea, and the iridectomy, and yet one more most 
important one, the power of removing the lens without any traction 
instrument. It is in my opinion to be preferred, as a rule, to any 
other mode of extraction, more especially in hospital practice, as 
the patient requires far less watching and attendance, and the after- 
treatment is extremely simple. The confinement to the bed and 



DIVISION OF CATARACT. 291 

house is also much shorter than in flap extraction. I think it is 
especially indicated in very feeble, decrepit, nervous, and unman- 
ageable patients, or those suffering from severe cough, or bronchitis ; 
also if the pupil is adherent, or small and rigid, so that it dilates 
but imperfectly under the influence of atropine, or if the cataract is 
complicated with some choroidal or retinal lesion. It is also the 
safest operation for diabetic cataract, for in the flap extraction 
(even with a preliminary iridectomy), there is always some risk of 
suppuration of the cornea in these patients, as they are generally in 
a very feeble state of health. As the iris is exceptionally impatient 
of irritation and bruising in cases of diabetes, it may be advisable, 
in order to secure the greatest immunity from this danger, to make 
a double iridectomy, viz., upwards and downwards, so as to get a 
broad vertical pupil, the two opposite portions of the iris being thus 
completely cut off from each other. I am sometimes asked by medi- 
cal practitioners and students which operation I consider the easiest 
and safest for an inexperienced operator. I think that, all things 
considered, the downward flap operation is the easiest, for when the 
section has been successfully completed, the chief danger and diffi- 
culty are past ; whereas in the modified linear extraction the iri- 
dectomy is superadded. I should, therefore, recommend that when 
the surgeon has operated several times by the lower flap extraction, 
and has acquired some experience and dexterity, he should pass on 
to the upper flap extraction, and Von Graefe's operation. The only 
two points in the latter which demand practice, care, and dexterity, 
are the incision and the removal of the lens. If the section is too 
small, the delivery of the lens will be difficult and forced, and will 
necessitate enlargement of the incision, considerable pressure upon 
the eyeball, or the introduction of some form of traction instrument. 
If, on the other hand, it is too large and lies too far in the sclerotic, 
there is imminent risk of losing much vitreous humor, perhaps even 
before the removal of the lens is attempted. Considerable nicety 
and care are also required in coaxing out the lens by pressing upon 
the cornea with the curette, for if this is roughly and clumsily done 
the hyaloid may be ruptured, the vitreous escape, and the lens will 
probably be pushed somewhat aside, and a scoop will have to be 
employed for its removal. 



9.— INCLINATION OR COUCHING. 

I only mention this operation to state that, in my opinion, it should 
be completely abandoned. Although it may appear to be tempo- 
rarily successful, it has been found that ultimately about 50 per cent, 
of the eyes have been lost from chronic irido-choroiditis, etc. 



10.— DIVISION OR SOLUTION OF CATARACT. 

This operation is more especially indicated in the cortical cata- 
ract of children and of young persons up to the age of twenty, or 



292 DISEASES OF THE CRYSTALLINE LENS. 

even twenty-five; also in those forms of lamellar cataract in which 
the opacity is too extensive to allow of much benefit being derived 
from an artificial pupil. After the age of thirty-five or forty, the 
lens is generally too hard to undergo anything but very slow ab- 
sorption, even after frequent repetitions of the operation ; the iris is 
also more impatient of irritation and pressure, so that the danger 
of setting up iritis is much increased ; and there are other opera- 
tions which are much to be preferred for cataracts occurring at this 
time of life. In infants and young children, an operation for cata- 
ract should not be unnecessarily postponed, as the presence of the 
cataract is very apt in infancy to give rise to nystagmus, and to 
that form of amblyopia which is dependent upon non-use of the 
eyes, and which is similar in character to that so often met with in 
strabismus. 

The object of the operation of division is to lacerate the anterior 
capsule with a fine needle, so as slightly to break up the surface of 
the lens and to permit the aqueous humor to come into contact with 
the lens substance, which, imbibing the fluid, softens, and "becomes 
gradually absorbed. The time required for the absorption varies 
with the age of the patient and the consistence of the cataract. In 
infants and young children, the lens is often absorbed in from six 
to ten weeks, and one operation may suffice for this purpose. But 
in adults it may have to be repeated several times, and in them 
great care should be taken not to divide the capsule and the lens 
too freely at one sitting, for this will cause great swelling of the 
len^substance, or the exit of considerable flakes into the anterior 
chamber, and either of these causes may set up severe iritis or irido- 
cyclitis. The same caution is necessary in cases of lamellar cata- 
ract, because in these, a large portion of the lens is transparent and 
of normal consistence, and will therefore imbibe much aqueous 
humor and swell up very considerably. 

[There are two operations for division of cataract, viz. : Division 
through the cornea, or the anterior operation for absorption ; and 
division through the sclerotic, or the posterior operation for ab- 
sorption. 

Division through the Cornea.'] — Prior to the operation, the pupil 
should be widely dilated with atropine. The patient, more espe- 
cially if a child, should be placed under the influence of chloroform. 
Infants should be firmly rolled in a blanket or sheet so that their 
movements may be controlled. The eyelids are to be kept apart 
with the spring speculum, and the eye fixed with a pair of forceps. 
A very fine needle is then to be passed somewhat obliquely through 
the outer and lower quadrant of the cornea, at a point lying well 
within the dilated pupil, so that the iris may not be touched by 
the stem of the needle during the breaking up of the lens. The 
track of the corneal wound must not be too slanting, otherwise its 
channel will be too long, and the tissue of the cornea will be 
stretched and bruised duriDg the working of the needle, and this 
may produce an opacity in the cornea ; nor must it be too- straight, 
otherwise the aqueous humor might easily escape. The size and 



DIVISION OF CATARACT. 293 

number of the incisions in the capsule must vary with the amount 
of effect that we desire. If the latter is to be but very slight, a 
single small horizontal or vertical tear may suffice, or a crucial in- 
cision of limited extent may be made. But if we desire a more 
considerable effect, more especially in the cortical cataract of chil- 
dren, the incisions must be more extensive, or the superficial por- 
tion of the lens is to be gently broken up or comminuted by a 
series of short superficial incisions, which converge towards the 
centre of the cataract. In infants and young children the needle 
may be far more freely used than in adults, or in cases of lamellar 
or partial cataract. In such, it is always safer to repeat the ope- 
ration, even several times, than to do too much at one sitting. It 
may be repeated at intervals of three or four weeks, if it is found 
that the absorption has become arrested or progresses but very 
slowly ; but all irritability and redness of the eye should have dis- 
appeared before the needle is again introduced. If the opening in 
the capsule is too large, or the cataract broken up too freely, the 
lens will imbibe much aqueous humor, and, swelling up very con- 
siderably, will press upon the iris and ciliary body, and may thus 
set up severe iritis or irido-cyclitis ; or if the incisions '%=- 

in the capsule are too extensive, fragments of lens sub- Fi g- In- 
stance may fall into the anterior chamber, and there set 
up great irritation. 

The needle used for this operation should be very small ; 
its cutting, spear-shaped point should only extend to 
about T ' 5 th or 2 X th of an inch from the end, and the 
stem should be cylindrical, so that the aqueous humor 
may be retained throughout the operation. I always use 
Bowman's fine stop needle (Fig. 112), which fulfils all 
these indications. 

[Division through the Sclerotic. — The pupil should be 
widely dilated with atropia, and the patient prepared for the ope- 
ration precisely as for the anterior puncturation. The knife-needle 
(Fig. 113), with its cutting edge looking upwards, is then passed 
through the sclerotic at a point on its transverse diameter a line 
and a half or two lines from the temporal margin of the cornea, and 
perpendicularly to the surface of the eyeball. " The puncturation 
should be made quickly, and the needle introduced only a short dis- 
tance. This accomplished, the surgeon should steady the eye with 
the needle, and wait an instant until the patient has recovered from 
the shock. The direction of the needle should then be changed, so 
that its point may be advanced between the iris and the lens, then 
the instrument should be steadily pushed on until its point reaches 
the opposite pupillary margin of the iris. In executing this step, 
care must be taken neither to wound the ciliary body or iris, nor 
to spit the lens on the needle. If the former accident happens, 
injurious inflammation may result ; if the latter, especially if the 
lens be hard, it will probably be dislocated, and in this case it 
should be at once extracted. "When the needle is pushed into the 
lens without dislocating it, the instrument should be carefully with- 



294 



DISEASES OF THE CRYSTALLINE LENS. 



Figs. 113, 114. 



drawn until its point is free, and then pushed on again in the proper 
direction. 

" This step being accomplished, the needle should be rotated one- 
quarter round its axis, so as to present its cutting edge towards and 
exactly over the diameter of the lens. This last movement is highly 
important, as the lens will thus offer the firmest resistance, and 
will not tilt over and be dislocated in being cut ; a free incision should 
then be made by withdrawing the needle a short distance, pressing 
firmly its edge against the cataract. If the lens be hard, several 
incisions should be made in the anterior capsule, and then this 
membrane freely lacerated crosswise with the point of the instru- 
ment ; this accomplished, the instrument should be withdrawn. 
The iens exposed to the aqueous humor will become softened, 
partly absorbed, and at a subsequent period the 
operation may be repeated, and the lens com- 
pletely broken up." 1 

The instrument recommended for this ope- 
ration is the knife-needle, devised by Dr. Isaac 
Hays, 2 of Philadelphia. The common straight 
needle does not cut well beyond a short distance 
from the point, unless it be made so thin as to 
endanger its breaking ; and with a curved needle 
it is impossible to divide up the lens. By means, 
however, of the knife-needle the division of a 
lens of even considerable hardness can be satis- 
factorily accomplished. 

The actual size of the knife-needle is repre- 
sented in the accompanying cut (Fig. 113). 
" This instrument, from the point to the bead 
near the handle (a to b, Fig. 114), is six-tenths 
of an inch, its cutting edge (a to c) is nearly 
four-tenths of an inch. The back is straight to 
near the point, where it is truncated, so as to 
make the point stronger, but at the same time 
leaving it very acute; and the edge of this 
truncated portion of the back is made to cut. 
The remainder of the back is simply rounded 

Ij off. jgThe cutting edge is straight, and is made 

to cut up to the part where the instrument be- 
comes round, c. This portion requires to be 
carefully constructed, so that as the instrument 
enters the eye it shall fill up the incision, and 
thus prevent the escape of the humors. In the 
magnified view of the instrument (Fig. 114) the 
proportions of the blade are not very accurately 
represented, the rounded part being rather too slender, and the 
handle should be octagonal, with equal sides, and of the same 
thickness its whole length."] 

1 "Lawrence on the Eye," edited by Hays, Phila., 1854, p. 727. 

2 "American Journ. of Med. Sciences," July, 1855, p. 81. 




DIVISION OF CATARACT. 295 

The after-treatment is generally very simple. The pupil should 
be kept widely dilated with atropine, so that the iris cannot be 
pressed upon by the swollen lens or any flakes that may have fallen 
into the anterior chamber. A bandage should be worn for the first 
twenty-four hours, and the patient should be kept in a somewhat 
darkened room for the first day or two, especially if there is much 
reaction. Generally, however, this is but slight, the eye only 
looking flushed, and watering somewhat on exposure to bright 
light. My friend, Mr. Lawson, has even successfully operated by 
this method upon some cases of monocular cortical cataract in 
adults (between the ages of twenty and thirty), and treated them 
throughout as out-patients. These were, however, exceptional 
cases, in which it was absolutely necessary that the patients should 
follow their employment. In order to expedite the cure, which is 
often of consequence in patients from the country, it is a very good 
plan, after the lens matter has become softened by the admission 
of the aqueous, to remove the whole cataract by a broad linear in- 
cision. In children this may generally be done within a week 
after the division, and thus the sight may be restored in a few days, 
whereas, otherwise, many weeks or even months would have elapsed 
before the cataract would have been entirely absorbed. The same 
proceeding may be employed in cases of partial cataract, the trans- 
parent portion of the lens being made opaque, and softened by the 
introduction of the needle. This mode of operation has been very 
successfully practised and much advocated by Mr. Bowman, who 
also often advantageously employs the suction syringe for the re- 
moval of the softened lens after it has been previously broken up 
by the needle. 

If symptoms of irritation and inflammation should set in after 
the operation of division, and they do not readily yield to antiphlo- 
gistics, but increase in severity, and more especially if the tension 
of the eyeball is augmented, the cataract should be at once removed 
through a good-sized linear incision, made near the periphery of 
the cornea with an iridectomy knife. This is also to be done if the 
capsule has been too freely divided, and the nucleus or considerable 
portions of lens substance have fallen into the anterior chamber, 
and are setting up much irritation. If the lens is so firm that it 
cannot all be readily removed through the linear section, it will be 
wiser to combine an iridectomy with it, than to endeavor to remove 
the portions of lens by repeated introductions of the curette into 
the anterior chamber. An iridectomy is also indicated if an in- 
crease of tension has existed for some little time, and if the per- 
ception of light and the extent of the field of vision are markedly 
deteriorated. 

Two special forms of inflammation may follow the operation, 
and endanger the safety of the eye. In the one, the inflammation 
is chiefly plastic or purulent in character. The iritis or irido ■ 
cyc'litis is accompanied by plastic exudations behind the iris, and 
into the vitreous humor, leading eventually in all probability to 
chronic irido-choroiditis and atrophy of the globe. In the other 



296 DISEASES OF THE CRYSTALLINE LENS. 

form, the inflammation is of a serous nature, giving rise to an 
increased secretion of the vitreous humor, and an augmentation of 
the intra-ocular tension — in a word, to a glaucomatous condition 
of the eyeball, which may cause irretrievable destruction of the 
sight if timely relief be not afforded. 

As these inflammatory complications are most apt to occur in 
adults above the age of fifteen or twenty, more especially if the 
cataract is only partial or of a lamellar nature, Von Graefe advises 
that in such cases, or if any posterior synechias exist, an upward 
iridectomy should be made a few weeks before the operation of 
division. By so doing, plenty of room will be afforded for the 
swelling up of the lens, and if fragments have fallen into the 
anterior chamber, they will produce far less irritation. 



11— OPERATIONS FOR LAMELLAR OR ZONULAR 
CATARACT. 

"When describing the nature of lamellar cataract, I mentioned 
that in those cases in which a sufficiently broad margin of trans- 
parent lens substance exists, great improvement of vision may 
often be attained by dilating the pupil by atropine. A glance at 
the accompanying figures will explain this. In Fig. 115, a repre- 
sents the undilated pupil occupied by the opacity b, which extends 

Fig. 116. 





beneath the iris as far as the dotted line c,- where the transparent 
margin d commences. As the latter is completely covered by the 
iris, the rays of light can only pass through the central opaque 
portion ; hence the indistinctness of vision. But when the pupil 
is dilated (Fig. 116) the transparent margin of the lens d is un- 
covered, and the rays can now pass through it to the retina. This 
fact is of great practical importance, for it furnishes us with a very 
valuable indication as to the treatment of such cases of lamellar 
cataract, for we may often succeed in restoring excellent vision by 
simply making an artificial pupil, without operating upon the lens 
itself. Such a proceeding possesses very marked advantages over 
any operation for the removal of the lens ; for the patient retains 
the power of accommodation, and is freed from the necessity of 
wearing cataract glasses, which are not only inconvenient, but also 
unsightly, more especially in youthful individuals. The artificial 
pupil may be made either by means of an iridectomy or an iridodesis. 
The former operation has the disadvantage that the base of the 
artificial pupil (Fig. 117) is opposite the periphery of the lens d, 





OPERATIONS FOR TRAUMATIC CATARACT. 297 

and may therefore give rise to a certain indistinctness of vision. 
on account^ of the rays being irregularly refracted by the edge of 
the cornea and lens, circles of diffusion on the retina being thus 
produced. In order to diminish this defect, the 
iridectomy should be but small. In most cases I Fig. 117. 

think Mr. Critchett's operation of iridodesis is to 
be preferred. A considerable portion of iris should 
be drawn out, in order that the entire pupil may 
be drawn near the margin of the cornea, for the 
iris will thus cover a large extent of the opaque 
portion of the lens. There will thus result a 
pupil like that in Pig. 118, having its apex, and Fig. 118. 

not its base, opposite the clear portion of the lens. 
Mr. Critchett has also in some cases obtained 
great improvement of sight by making a second 
iridodesis close to the other, thus gaining a some- 
what broader pupil, and admitting more light. 

If the transparent margin in lamellar cataract 
is not sufficiently broad or clear to admit of much improvement of 
vision by an artificial pupil, the lens itself must be operated upon, 
either by division with or without iridectomy, or by Von Graefe's 
operation. . 

In persons under 25, 1 think it best slightly to divide the lens 
with a needle, and to repeat this several times, and then, when the 
whole lens has become opaque and softened, to remove it through 
a large linear incision, or with the suction curette. It is never 
wise to operate upon both eyes at the same time, for in some cases 
eyes affected with lamellar cataract are extremely irritable, and 
considerable irido-choroiditis, with or without sloughing of the 
cornea, may supervene and destroy the eye. If this has occurred 
in the one eye, we should be greatly upon our guard in operating 
upon the second at a subsequent period, or devise some other mode 
of operating. In persons above the age of 25, 1 have succeeded 
very well in removing the lens by Von Graefe's operation. 



12.— OPERATIONS FOR TRAUMATIC CATARACT. 

If the wound in the lens is of but slight extent, and the patient 
young, the cataract may be left to absorption if no symptoms of in- 
flammation set in. The pupil should be kept widely dilated with 
atropine, and the condition of the eye carefully watched. If in- 
flammatory symptoms supervene, it may be necessary to remove 
the lens by linear extraction, more especially if it swells up con- 
siderably, or large portions have fallen into the anterior chamber 
and are setting up irritation. This operation should also be at 
once performed, if the wound in the lens has been considerable, so 
that the latter, imbibing much aqueous humor, becomes rapidly 
swollen and presses upon the iris and ciliary body. The simple 
linear extraction will generally suffice if the lens is so softened that 



298 DISEASES OF THE CRYSTALLINE LENS. 

it will readily escape through the incision. But if the nucleus or 
the greater portion of the lens is still firm, it may be more advisable 
to make a large iridectomy, in order to afford more room for the 
swelling of the lens, and then to leave the latter to undergo ab- 
sorption, which will now be attended by far less risk. In those 
cases in which great swelling of the lens is accompanied by severe 
inflammation, it will be best to make a large iridectomy, and re- 
move the cataract, either with or without the aid of the scoop. _ If 
there is much soft matter, this may be removed with the suction 
syringe, although I am rather afraid of its use in such cases, espe- 
cially if there is any iritis or irido-choroiditis, as it may easily pro- 
duce hypersemia ex vacuo of the inner tunics of the eyeball. If a 
foreign body — e.g., a chip of steel, glass, or gun-cap — is lodged in 
the lens, it is wiser to endeavor to remove it, together with the 
lens. This should be done by introducing a scoop well behind the 
foreign body and lifting it out; for if we permit the lens to un- 
dergo absorption, the foreign body will at last become disengaged 
and fall down into the interior or posterior chamber, and probably 
set up severe and even perhaps destructive inflammation. The 
situation of a bit of metal in the lens may often be recognized by 
the aid of the oblique illumination, when we may observe a little 
brown spot in the lens, or a little dark line showing the track of 
the foreign body. 

If the foreign body has passed through the lens and is lodged in 
the vitreous humor, retina, or choroid, great attention must be 
paid to the condition of the eye, as severe and destructive inflam- 
mation is but too likely to ensue. The degree of sight, the state 
of the field of vision, and the tension of the eyeball, should be espe- 
cially watched. If in such a case the lens swells up very con- 
siderably, it may be wise to perform linear or scoop extraction 
combined with a large iridectomy, in the hope that the absence of 
the lens may diminish the inflammation, although it must be re- 
membered that the chief exciting cause — the foreign body — still 
remains behind, and may at any time, even after the lapse of years, 
again set up inflammation. In all such cases of injury, the con- 
dition of the other eye must also be anxiously watched. At the 
earliest symptoms of sympathetic inflammation, or even of well- 
marked and recurrent sympathetic irritation, the wounded eye 
should be at once removed, for only thus can we insure the safety 
of the other. If the injury is so severe that the sight is greatly, 
and probably permanently, impaired, the immediate removal of the 
eye may be indicated, even although the other eye does not sym- 
pathize. This is especially the case amongst the laboring classes, 
who cannot be under our immediate supervision, or cannot afford 
the time to undergo a lengthened course of treatment without the 
hope of regaining any useful degree of vision. The same course 
may be advisable amongst the higher classes, if from circumstances 
— such as officers being ordered abroad, necessity for a long voyage, 
etc. — they cannot be under constant supervision, so that the earliest 
symptoms of sympathetic inflammation may be detected. 



REMOVAL OF SOFT CATARACT. 299 

13— REMOVAL OF SOFT CATARACT BY A SUCTION 
INSTRUMENT. 

In the extraction of soft cataract through a simple linear incision, 
some difficulty is occasionally experienced in removing the firmer 
portions without exerting a certain amount of pressure upon the 
globe, or introducing the curette into the anterior chamber. This 
difficulty has led Mr. Pridgin Teale' to the ingenious employment 
of a suction curette for the more easy and complete extraction of 
soft cataract. 

The instrument now used by Mr. Teale is almost identical with 
the one described in his original paper. It is represented in Fig. 
119, and consists of 3 parts: (a) a stem, formed of a glass tube, with 




(b) a tubular curette at one end, and (c) an India-rubber tube with 
a mouth-piece at the other end. (a) The hollow glass stem (_B) is 
5 inches in length, and allows the operator to watch the progress 
of the suction as the material is drawn into the transparent tube. 

(b) The India-rubber tube (C) is about 12 inches in length, and fur- 
nished with a mouth-piece which enables the operator to apply the 
suction either with considerable force or the most exquisite gentle- 
ness, using his tongue as a piston, under the most perfect control. 

(c) The curette (A) is about f of an inch in length and of the same 
size as an ordinary curette ; it is slightly convex on its upper sur- 
face and not flat, and its whole calibre does not require a larger 
opening in the cornea than the common curette. The point should 
be as round and blunt as possible, and the opening on the upper 
surface should be equal in size to the section of the tube, and as 
near to the extremity as the required bluntness will permit. Mr. 
Teale performs the operation in the following manner : The pupil 
having been well dilated by atropine, a puncture is to be made in 
the cornea with a broad needle at a point opposite the margin of 
the fully dilated pupil, and, passing obliquely through the substance 
of the cornea, the instrument should enter the anterior chamber at 
a point opposite the margin of the pupil when of medium size. 
Such a valvular opening will prevent any scar in front of the pupil, 

1 "R. L. O. H. Rep.,"iv. 3, 197. 



300 



DISEASES OF THE CRYSTALLINE LENS. 



Fig. 120. 



and diminish the risk of prolapse or an anterior synechia. The 
capsule having been freely divided, the curette should be carefully 
introduced through the corneal wound, and its end (the opening 
looking towards the cornea) held steadily in the area of the pupil 
and gently buried in the opaque matter, the convex surface being 

pressed somewhat back towards the pos- 
terior capsule. The suction power should 
then be carefully applied and continued 
in gentle draws, as long as any~ opaque 
matter comes forward into the pupil, and, 
when the latter is quite clear, the instru- 
ment is to be withdrawn. On no account 
is the curette to sweep either in front or 
behind the iris in search of opaque matter. 
Mr. Teale has found this mode of ope- 
rating extremely successful, the recovery 
being very speedy, and the operation fol- 
lowed by little or no irritation. He con- 
siders it applicable in all full-bodied com- 
plete cataracts in persons under the age of 
40 ; including in this category spontaneous, 
diabetic, and those traumatic cataracts in 
which, from the rent in the capsule being 
of moderate extent, the eye remains quies- 
cent until the cataract is completely formed. 
Finally, incomplete cataracts which have 
been rendered complete by division of the 
capsule. He thinks it unsuitable in those 
forms of complete or immature cataracts 
in which portions are transparent and glu- 
tinous, and require great force to draw 
them into the curette ; also in traumatic 
cataract, if there is much irritability or 
iritis, if there has been rupture of the pos- 
terior capsule, or if so much of the lens 
has been absorbed that the anterior and 
posterior capsule are nearly in contact ; or 
in degenerate cataract. 

Mr. Bowman has devised an excellent 
suction syringe (Fig. 120), the use of which 
is very easy, and which can be regulated 
with great nicety. 1 The operator, having 
made an incision in the cornea with the 
broad needle, and freely divided the lens, 
can introduce the nozzle of the instrument 
(which is to be held in the right hand) in 
the corneal aperture, and gently " suck out" 
the soft lens substance. 




After Lawson. 



1 Both Mr. Teale's and Mr. Bowman's instruments are made by Messrs. Weiss. 



SPERINO'S TREATMENT OF CATARACT. 301 

Although it? appears that the idea of employing suction for the 
removal of cataract dates back as far as the fourth century, and that 
it has since been advocated by several authors, more especially in 
later years, by Blanchet and Langier, it never attained a recognized 
position until it was introduced by Mr. Teale. This operation has 
now met with much and deserved favor, more especially at the 
Royal London Ophthalmic Hospital, Moorfields, where it has been 
employed with marked success. It is especially indicated in soft 
cortical cataract, which may generally be very readily and com- 
pletely removed by the suction instrument. If the cataract be 
somewhat more firm in consistence, it will,.be well to break it up 
with the needle a few days previously. I have ajso used it with 
much advantage in removing portions of soft cortical substance 
which have remained behind in the pupil in the operations for 
senile cataract, either in the common flap or Von Graefe's operation, 
for such portions may often be more readily and thoroughly re- 
moved in this way than by rubbing the eyeball or the reintroduc- 
tion of the scoop. Some care and delicacy are, however, required 
in the use of this instrument,«for, if too great a suction power is 
employed, hypersemia (ex vacuo) of the iris and the deeper tunics of 
the eyeball may easily be produced. 



14.— SPERINO'S TREATMENT OF CATARACT BY 
PARACENTESIS. 1 

This mode of treatment is chiefly based upon the theory that 
the impairment of vision in cataract is partly dependent upon a 
temporary disturbance in the intra-ocular circulation, especially an 
occasional state of congestion of the choroid, and partly upon the 
opacity of the lens. Dr. Sperino holds that the opaque lens fibres 
may regain their transparency as long as their intimate structure 
is not disorganized, which always follows, more or less rapidly, 
upon the opacity, but less so in old than in young persons. JSTow, 
as the operation of tapping the anterior chamber relieves the intra- 
ocular circulation, it often produces a marked and immediate im- 
provement in the sight, and in some cases often-repeated tappings 
have at last effected a complete cure. In others their effect has 
been but moderate, or even negative. The operation consists in 
making a small puncture with a broad needle at the edge of the 
cornea or slightly in the sclerotic ; a blunt probe is then inserted 
between the lips of the wound, and the aqueous humor slowly 
evacuated. The evacuations by the same opening may be made 
repeatedly during a single sitting, followed by an interval of 
several days, or singly at an interval of a day or two. The opera- 
tions in cataract were repeated a great number of times. In one 
case 167 tappings were made, and finally linear extraction was 

1 Vide a most interesting work by Dr. Sperino, entitled "Etudes Cliniques sur 
l'Evacuation r6p£tee de l'Humeur aqueuse dans les Maladies de l'CEil," Turin, 
1862. Also a review of this work in the "Ophthalmic Review," ii. p. 294. 



302 DISEASES OF THE CRYSTALLINE LENS. 

performed. I am not aware that this treatment has heen adopted 
by any other surgeon on a sufficiently large scale to warrant any 
exact conclusion as to its efficacy. It would be, I think, very 
difficult to find patients who would submit to such a very pro- 
tracted course of treatment and such numerous operations. 



15.— OPERATIONS FOR CAPSULAR AND SECONDARY 
CATARACT. 

I have already stated that capsular cataract often occurs in 
retrogressive le.nticular cataract, and that in such cases it may be 
advisable to remove the lens in its capsule. If, in an operation for 
senile cataract, the capsule is found so tough and thickened that it 
resists the pricker, it should be torn across with a sharp hook, and 
then, after the extraction of the lens, the capsule should be re- 
moved by the hook or a pair of forceps. In such cases, the con- 
nection between the posterior capsule and the hyaloid is not 
unfrequently loosened, and the lens»may often be readily extracted 
in its capsule by the hook.. Some operators, in making the section, 
divide the tough capsule across with the point of the knife. 

Secondary cataracts vary much in thickness and opacity. They 
may be produced by portions of lens substance remaining behind 
and becoming entangled in the capsule, by the deposition of lymph 
upon the latter, or by the proliferation of the intra-capsular cells. 

Again, if the more fluid constituents of a cataract become 
absorbed and the cortical substance undergoes chalky or fatty 
degeneration, the lens gradually dwindles down, and assumes the 
appearance of a flattened, shrivelled disk. 

Mr. Bowman 1 has also called special attention to another form 
of secondary cataract, in which the capsule, though quite trans- 
parent, is crumpled or wrinkled, and thus produces much confusion 
of vision by irregularly refracting the rays of light. This condition 
of the capsule may easily escape detection, even although the eye 
be examined with the oblique illumination, and is not perhaps 
noticed until the ophthalmoscope is employed, when the observer 
finds that he cannot obtain a clear and distinct view of the optic 
disk, but that it looks somewhat distorted. On then getting the 
capsule itself into focus, the wrinkles may be readily observed. 

No operation for secondary cataract should be performed until 
the eye has quite recovered from the cataract operation, and is 
entirely free from all irritation. Generally three to four months 
should be allowed to elapse between the two operations. Nor 
should it be done if the area of the pupil is not of a good size. If 
it has become contracted, or is partially occupied by lymph, or if 
there are extensive posterior synechias, a preliminary iridectomy 
should be made, and then, when the eye has become quiescent, the 
operation upon the capsule may be performed. 

1 "R. L. O. H. Rep.,"iv. 



CAPSULAR AND SECONDARY CATARACT. 303 

Formerly ,_ the favorite mode of operating was by the removal of 
the obstructing membrane. But this is falling more and more into 
disuse, as it often proves a very dangerous operation, and is far less 
safe than opening up the membrane by the needle, which is attended 
by much less risk of setting up inflammation. Moreover, it is a 
well-established fact that a small clear aperture in the opaque 
membrane will afford most excellent sight. 

For the needle operation chloroform is hardly necessary, unless 
the patient proves very unmanageable. The eyelids should be 
kept apart with the stop-speculum, and the eye may be steadied 
with the forceps. Bowman's fine stop-needle should then be passed 
through the cornea at a short distance from the margin, and the 
operator should endeavor to tear a hole in the centre of the opaque 
membrane. The portion which is thinnest, least opaque, and con- 
sists chiefly of wrinkled capsule, should be selected for this purpose. 
It is to be torn across in different directions, the point of the needle 
comminuting the membrane, without, however, being allowed to 
go deeply into the vitreous humor. If the operator finds, after 
one or two ineffectual attempts to transfix it and tear it through, 
that ' the false membrane yields before the needle and eludes it, or 
if it is too tough and firm to be torn through, he should at once 
have recourse to a second needle. This is to be passed into the 
anterior chamber from an opposite point of the cornea. Transfixing 
and steadying the false membrane with the needle held in his left 
hand, the operator employs the other needle to tear the membrane 
and open it up. Or the points of the needles may be made to cross 
each other, and then, after being revolved a few times round each 
other, be separated, which will cause the membrane to be torn 
across. Great care must be taken to use the needles with extreme 
delicacy, and not to drag roughly upon the adhesions between the 
capsule and the iris, otherwise severe inflammation may be set up. 
If any portion of the iris should have been considerably dragged upon 
during the use of the needles, it may be advisable to excise this seg- 
ment, in order to allay any tendency to inflammatory reaction. This 
ingenious double-needle operation was first devised by Mr. Bow- 
man, 1 and has proved a most valuable addition to Ophthalmic Sur- 
gery. Should the false membrane be found but slightly adherent 
to the iris, bo that it floats almost freely in the pupil, the adhesions 
may be torn through by the needle, and the whole membrane ex- 
tracted by the canula or small iris forceps through a linear incision. 
If the adhesions are found to be so firm that a good deal of force 
would have to be employed to break them down or to divide them, 
this should on no account be attempted ; but the free portion should 
be caught by a sharp hook, gently drawn through the linear inci- 
sion, and snipped off, which will leave a good-sized opening in the 
capsule. 

In cases of chalky or siliculose cataract, in which the capsule 
looks like a little wrinkled bag containing small chalky chips of 

1 " Med. Chir. Trans.," 1853, p. 315. 




304 DISEASES OF THE CRYSTALLINE LENS. 

lens, it may be possible to remove the whole capsule with a sharp 
hook through a good-sized linear incision, as in Fig. 121. But it 
is often a very dangerous operation, setting up perhaps severe irido- 

choroiditis, which may even lead to 
Fi S- 131 - atrophy of the eyeball. 

After an operation for secondary 
cataract, atropine should be applied, 
the patient be kept in a somewhat 
darkened room for a few days, and 
carefully watched, in order that the 
first symptoms of inflammatory reac- 
tion, accompanied, perhaps, by in- 
creased intra-ocular tension, may be 
detected. Within from twelve to 
twenty-four hours of the operation, 
the patient may experience a good 
deal of pain in and around the eye, 
and down the corresponding side of 
.„ .. „ the nose (ciliary neuralgia) ; there is 

After Stellwag. . v J , . ° . '. ' n . . 

perhaps some subconjunctival injec- 
tion and lachrymation, and the sight appears somewhat cloudy. 
Great benefit is often experienced from the use of very cold (iced) 
compresses after this operation, as they diminish the irritation, and 
often cut short an attack of severe inflammation. On trying the 
tension of the eyeball it is found increased, and the iris pushed for- 
ward (sometimes partially), so that the anterior chamber is narrowed. 
If the intra-ocular tension is considerably increased (T 2), and this 
persists for twelve hours from the commencement, Mr. Bowman 1 
strongly advises that the bulging part of the iris should be punc- 
tured with a broad needle, thus establishing a communication be- 
tween the anterior and posterior chambers, which will generally 
diminish the intra-ocular pressure and cut short the inflammation. 

Dr. Agnew, 2 of New York, has devised the following operation. 
He passes a stop needle through the centre of the membrane, thus 
fixing both the eye and the latter ; he then makes a linear incision 
on the temporal side of the cornea, through which he passes a small 
sharp-pointed hook, the point of which is passed into the same 
opening in the membrane as the needle. He now tears the mem-, 
brane, and by a rotatory movement of the hook rolls it up round 
the latter, and then either draws it out altogether, or if this cannot 
be done, he tears it widely open. 

For those cases in which severe and protracted inflammation has 
followed the removal of cataract, giving rise to a dense secondary 
cataract, Dr. Noyes, of New York, has devised the following ope- 
ration, 3 which he has performed with much success. He makes a 
puncture at the centre of the outer margin of the cornea, with 
Graefe's cataract knife, carries it across the anterior chamber, and 

' "R. L. 0. H. Rep.," iv. 366. « "Kl. MonastsM.," 1865, p. 389. 

' "R. L. O. H. Rep.," vi. 3, 209. 



DISLOCATION OP THE LENS. 305 

makes the counter puncture at a corresponding point on the opposite 
side ; he then partially withdraws the knife until its point arrives 
opposite the middle of the iris, when he plunges it backwards 
through the false membrane into the vitreous, making the wound 
as large as possible. After withdrawal of the knife, a small blunt 
hook is to be passed in through each corneal wound, and caught in 
the wound made in the iris (false membrane ?), and traction made 
in opposite directions, so as to drag out a portion of tissue at each 
corneal wound, where it is to be snipped off. Thus a large central 
pupil will be made. 

16— DISLOCATION OF THE LENS (ECTOPIA LENTIS). 

The dislocation of the lens may either be partial or complete. 
In the latter case it may be displaced into the vitreous or aqueous 
humors, or beneath the conjunctiva. 

Partial Dislocation. — In the slightest degree of partial displace- 
ment, the lens is simply turned somewhat upon its axis, one por- 
tion of its periphery being tilted obliquely forwards against the 
iris, the other backwards and away from the latter. Or again, 
the dislocation may be eccentric, 

the lens being somewhat shifted [Fig. 122. 

towards a certain direction, so . ,. ^mmtmess^^^-^. 

that its centre no longer corre- 
sponds to the optic axis, but lies 
more or less considerably, to one 
side of it ; the periphery of the 
lens may even lie across the nor- 
mal pupil. [Fig. 122.] This form 
of displacement generally occurs 
in a downward direction ; but it After Lawson.] 

may also take place upwards and 

inwards, or upwards and outwards. Such partial displacement of 
the lens may be occasioned by various causes, amongst others by 
anterior synechia, for if in such a case an adhesion exists between 
the iris and the capsule of the lens, the latter is drawn forwards 
with the iris at this point, and therefore somewhat displaced or 
tilted. It may also occur, as Stellwag has pointed out, in cases of 
anterior scleral staphyloma. 

On examining an eye affected with partial displacement of the 
lens, we find that when it is moved rapidly about in different 
directions, the iris is slightly tremulous at the point where it has 
lost the support of the lens, where the latter has receded from it. 
Moreover, it is here also somewhat cupped or curved hack, being 
on the other hand pushed forward and prominent at the point 
where the edge of the lens is tilted forward against it. In the 
former situation, the anterior chamber will consequently be slightly 
deepened, in the latter narrowed. If the pupil is widely dilated 
with atropine, we can easily recognize the altered position of the 
lens by the aid of the oblique illumination, or still better, by the 
20 




306 DISEASES OF THE CRYSTALLINE LENS. 

direct examination with the ophthalmoscope. "With the latter, 
the free edge of the lens will be noticed as a sharply defined, dark, 
curved line, traversing the red fundus, and forming the outline of 
a transparent or opaque lenticular disk. If the displacement is so 
great that a considerable portion of the background of the eye can 
be examined through that part of the pupil in which the lens is 
absent, a distinct erect image of the details of the fundus will be 
obtained. In the reverse image, the prismatic action of the edge 
of the lens can be easily observed, for then the double image of the 
fundus will appear, and the two images cannot be simultaneously 
distinctly seen ; .for whilst the one is clearly defined, the other 
will appear hazy, and in order to render the latter distinct, either 
the position of the observer's eye or of the ocular lens must be 
changed. Such a partial displacement of the lens will also have a 
peculiar effect upon the patient's sight, for he will generally be 
affected with monocular diplopia, or polyopia, which is due to the 
difference in the refraction of the two portions of the pupil, and to 
the prismatic action of the peripheral portion of lens which lies 
across it. The state of refraction will also differ in the two por- 
tions of the pupil, for in that in which the lens is absent, a very 
considerable degree of hypermetropia will exist. Yon Graefe 1 
mentions a case of displacement of the lens, in which, when the 
patient was endeavoring to distinguish a small object, the eye 
deviated in a certain direction, in order that the rays might 
impinge upon the central portion of the lens. If the pupil is 
small, the patient may observe the edge of the displaced lens 
entoptically, or the same phenomenon may be produced with a 
dilated pupil,. if he looks through a minute aperture in a card or a 
stenopaic apparatus. 

If the dislocation of the lens is due to an accident, etc., e.g., a 
severe blow upon the eye, the sight is often greatly impaired 
directly afterwards by hemorrhage into the aqueous and vitreous 
humors. As the blood becomes absorbed the sight may gradually 
improve, if there is no other deep-seated lesion. 



17— COMPLETE DISLOCATION OF THE LENS. 

Into the Vitreous Humor. — The iris will be observed to be markedly 
tremulous when the eye is moved in different directions, and the 
anterior chamber will be somewhat deepened. If the catoptric 
test be employed, it will be found that the lenticular reflections 
are wanting. On examining the eye with the oblique illumination, 
the absence of the reflection from the anterior capsule will also be 
noticed, and the position of the .displaced lens will in most cases 
be easily recognized, more especially if the pupil is dilated, as a 
portion of the lens generally occupies some part of the pupil, or 
floats across it when the eye is moved. If the lens is opaque, the 

"A. f. 0.,"i. 8,291. 



COMPLETE DISLOCATION OF THE LENS. 



307 



sight will of course be temporarily lost when the lens lies across 
the pupil. The position of the iens will vary with that of the 
head. If the latter is held erect, it will sink down into the 
vitreous humor ; if the head is bent forward, the lens will fall 
against the pupil, or may even pass through it into the anterior 
chamber. With the ophthalmoscope, the situation of the lens in 
the vitreous humor can be very easily ascertained, for it will 
appear in the form of a darkish lenticular body, generally lying iu 
the lower portion of the vitreous humor. The latter is of course 
more or less fluid, generally entirely so. In spontaneous luxations, 
the lens is frequently opaque, and in such cases the sight will be 
greatly improved. Even if it is transparent at the time of the 
displacement, it generally becomes opaque in the course of a few 
months. In such cases the cataract may assume the lamellar form, 
only some layers around the nucleus becoming clouded. But a 
dislocated lens may retain its transparency for very many years, if 
its capsule is uninjured. Mooren has seen a case in which the lens 
remained clear for 36 years. 1 When the lens has sunk into the 
vitreous humor out of the area of the pupil, the eye will be 
extremely hypermetropic, in fact, in a similar condition to one 
operated on tor cataract. 

Dislocation of the Lens into the Anterior Chamber. — Although this 
condition may occur in a transparent lens, it is more frequent when 
the latter is chalky, and per- 



haps diminished in size. The 
displacement is moreover gene- 
rally spontaneous and gradual, 
and not due to an accident. 
There can be no difficulty in 
recognizing the affection, for in 
the anterior chamber w ill be ob- 
served a lenticular disk, either 
transparent and diaphanous, 
or white and opaque. [Fig. 123.] 
If the lens is in its capsule, 
a sharply defined yellow bor- 
der will be noticed encircling 
the disk (Graefe). The lens 
may be either entirely in the 
anterior chamber, or a part 
may lie in and behind the 
pupil. The latter condition is 
especially dangerous, as the 
presence of the lens in the 
pupil is apt to set up irritation 
and inflammation of the iris, 
from maintaining a constant 
" teasing;" and contusion of the 



[Fig. 133. 




After T. W. Jones.l 



Oplithalmiatrische Beobacktungen, 257. 



508 



DISEASES OP THE CRYSTALLINE LENS. 



edges of the pupil. In some cases the lens does not retain its posi- 
tion in the anterior chamber, but falls back again into the vitreous 
humor, and it may thus frequently alternate in its position, being 
sometimes found in the anterior chamber, at others in the vitreous. 
Its presence in the anterior chamber will cause a considerable deep- 
ening of the latter, and a cupping back of the iris. Adhesions are 
sometimes formed between the capsule and the cornea; the latter 
may even ulcerate and the lens escape through the perforation 
(Graefe). 1 

Severe inflammatory symptoms may also supervene, implicating 
the cornea, iris, and the deeper structures of the eyeball, and ac- 
companied perhaps by an increase in the intra-ocular tension. 
There is often also very severe periodic ciliary neuralgia. But the 
inflammation may even extend sympathetically to the other eye. 
On the other hand, the lens may remain for a very long period in 
the anterior chamber without producing any irritation or pain. 

Dislocation of the Lens under the Conjunctiva. — This is always due 
to an accident, generally to a heavy blow from some blunt substance, 
hitting the eye below, and knocking it forcibly against the roof or 
upper edge of the orbit, hence the most frequent seat of this dis- 
placement is upwards and inwards, or upwards and outwards. The 
rupture in the choroid generally occurs quite anteriorly, between 
or in front of the insertion of the recti muscles, This form of dis- 
location is most frequently met with in persons after the age of 
thirty or forty, when the sclerotic has lost its elasticity. It is 
characterized by the following appearances: Beneath the con- 
junctiva is noticed a small, well marked, prominent tumor [Fig. 

124], which may even cause a 
[Fig. 124. little circumscribed prominence 

of the lid. The color of the 
tumor varies, it may be dark from 
the presence of effused blood in 
and beneath the conjunctiva, or of 
a portion of prolapsed iris; or the 
conjunctiva may be transparent, 
and only slightly injected, and 
then the grayish-white lens can be 
easily recognized. But in some 
After Lawson.] cases only a part of the lens has 

escaped beneath the conjunctiva, 
the rest remaining within the eye. Whilst the sclerotic has been 
ruptured, the conjunctiva, on account of its laxity and elasticity, 
has generally yielded before the lens, and has not given way or been 
torn, but covers the displaced lens. The pupil is mostly irregular 
.and drawn up, and there is a more or less considerable prolapse of 
the iris. If the capsule has been ruptured and the lens escaped 
from it, the remains of the torn shreds of capsule will be seen with 
the ophthalmoscope, just as after an operation for cataract. 




"A. f. 0.,"i. 1,343. 



COMPLETE DISLOCATION OF THE LENS. 309 

Dislocation of the lens may be spontaneous, and is then gener- 
ally due to a gradual relaxation or elongation of the suspensory 
ligament, or its partial rupture. In such cases the lens is often 
opaque, and the vitreous humor perhaps fluid. Moreover, in such 
a condition a very slight shock to the eye, which has perhaps been 
unnoticed by the patient, will produce dislocation of the lens. The 
affection may also be congenital, and even hereditary, occurring in 
several members of the same family. Thus, Mr. Dixon 1 mentions 
a case in which a partial displacement of the lens existed in a 
mother and three sons. Mr. Bowman narrates a case in which a 
patient, suffering from dislocation of the lens, had two uncles 
affected with the same disease. If the affection is congenital, it is 
generally accompanied by more or less amblyopia, and perhaps 
nystagmus, and such eyes are as a rule also very myopic. In such 
cases the dislocation mostly exists in both eyes. But the most 
frequent cause is an injury to the eye from blows or falls upon this 
organ, which cause a rupture of the suspensory ligament, and a 
more or less complete dislocation of the lens. Mr. Bowman 2 has 
called attention to the fact that glaucomatous symptoms occasion- 
ally arise in cases of dislocation of the lens. 

According to Von Graefe, 3 partial displacements of the lens, de- 
pending upon relaxation or rupture of the zonula, appear to be more 
prone to excite an increase of the eye-tension, than if the disloca- 
tion is complete, and the lens is freed from its attachment and 
floats about. For in the latter instances, glaucomatous symptoms 
generally only supervene if the lens periodically pushes the iris for- 
ward or becomes jammed in the pupil, or between the iris and the 
cornea. As long as the capsule remains entire, we must assume 
that the secondary glaucoma which sometimes supervenes on dis- 
placement of the lens is partly due to a stretching of the zonula 
and ciliary processes, and partly to the pressure of the lens upon 
the iris and ciliary region, which sets up irritation. The glau- 
coma sometimes assumes the simple form, in other cases the inflam- 
matory, accompanied by serous iritis. 

The treatment of dislocation of the lens must vary according to 
the exigencies of the case. Where it is but slight, the sight may 
not be materially affected, and no operative interference may be 
indicated. If, however, the displacement is so considerable, that 
the free edge of the lens lies in the pupil, and thus gives rise to great 
impairment of the sight, and very annoying diplopia, an endeavor 
should be made to remedy this defect. The best mode of treatment 
is that originally adopted by Wecker, 4 viz., an iridodesis made in 
the opposite direction to that in which the lens is displaced, so that 
the artificial pupil will be brought opposite that portion of the eye 
in which the lens is deficient, and the iris will be drawn over the 
displaced lens, and cover the latter to a more or less considerable 

1 "Rov. Loud. Ophthal. Hosp. Reports," i. 54. 

2 "R. L. 0. H. R ," v. 1. 3 "A. f. 0.," xv. 3, 156. 
1 Vide Wecker, 2d edition, p. 94. 



310 DISEASES OF THE CRYSTALLINE LENS. 

extent. The patient will then be in the condition of a person 
whose lens has been extracted, and he will be able to see well both 
at a distance and near at hand through suitable convex glasses. 
For obvious reasons, iridodesis is in such cases to be preferred to an 
iridectomy. If the lens is completely dislocated into the vitreous 
humor, and is setting up no disturbance, it is wiser not to interfere. 
But if inflammatory complications arise, or the sight is much im- 
paired by the lens floating about across the pupil when the eye is 
moved, it will be best to remove it. An iridectomy should be 
made opposite the point towards which the lens is displaced, and the 
latter is then to be removed by Critchett's scoop. The operation is, 
however, often very dangerous, for a considerable amount of fluid 
vitreous will be lost, and severe irido-choroiditis, with subsequent 
atrophy of the globe, may supervene. 

When the lens is luxated into the anterior chamber, we may en- 
deavor to obtain its re-position into the vitreous humor, by making 
the patient assume the horizontal posture, and applying a compress 
bandage. If it falls back into the vitreous humor, its maintenance 
in this situation may be assisted by an iridodesis, or temporarily by 
the application of the solution of Calabar bean. If the presence of 
the lens in the anterior chamber sets up inflammatory reaction, or 
impairs the sight, it should be extracted with the scoop, and it will 
be better to combine an iridectomy with this operation. The in- 
cision should be made in the lower part of the cornea with G-raefe's 
cataract knife. To prevent the escape of the lens into the vitreous 
humor, Wecker advises that it should be transfixed with a needle, 
and kept in its position in the anterior chamber, until the scoop 
can be introduced beneath it. If the lens simply disturbs the sight 
without setting up any inflammation, we may endeavor to gain its 
absorption by the operation of division, care being taken not to 
lacerate the capsule too freely, but rather to repeat the operation 
several times. 

In the subconjunctival dislocation, an incision should be made, 
and the lens removed ; and the prolapsed portion excised, so that 
the wound may be quite smooth. If a tolerably firm union of the 
lips of the wound has already taken place, it will suffice to apply a 
compress bandage ; but if the rupture in the sclerotic is gaping, it 
will be better to unite its edges with one or two fine sutures, in the 
same manner as has been advised for incised wounds in this region. 

With regard to the treatment which is to be pursued if symp- 
toms of glaucoma arise in cases of displacement of the lens, Von 
G-raefe 1 advises that where the displacement is moderate, and the 
iris partially pushed forward, an iridectomy should be made, and 
the portion of iris which is pushed forward removed. It is of im- 
portance that the incision should be very peripheral, for otherwise 
the entrance of the vitreous humor into the anterior chamber pushes 
back the iris, and renders its excision very difficult. He points 

1 "A. f. 0.,"xv. 3, p. 157. 



COMPLETE DISLOCATION OF THE LENS. 311 

out, moreover, that the removal of the lens is apt, in such cases, to 
prove especially dangerous, for as there is a free communicatiou 
between the anterior chamber and vitreous space, and the intra- 
ocular tension is increased, it is impossible to prevent a great 
escape of vitreous humor, which may be accompanied by serious 
intra-ocular hemorrhage. But if the iridectomy proves insufficient 
to stay the glaucomatous symptoms, or if the lens is completely 
luxated, it will be necessary to remove the latter. 



Chapter VI. 
THE USE OE THE OPHTHALMOSCOPE. 



, It was formerly supposed that the black appearance of the pupil 
is due to the fact that all the light which enters the eye is absorbed 
by the choroid, and consequently that none is reflected towards the 
observer! This, however, is not the case, for a considerable portion 
is diffusely reflected, and may be caught up by the observer's eye 
if this is placed in the direction of the emerging rays. In such a 
case, the pupil no longer appears black, but is luminous, having a 
bright red glow. Cumming, in 1846, pointed out that all normal 
eyes are luminous, more especially if the pupil is dilated ; but that 
it is necessary, in order to obtain this luminosity, that the eye of 
the observer should be placed parallel to the incident rays, that is, 
as nearly as possible in the direct line between the source of light 
and the eye observed. But in the ordinary mode of examination 
this is next to impossible, as the observer's head must be placed 
between tbe light and the patient's eye, and will, therefore, cut off 
the rays passing to the latter. Moreover, even if some of the re- 
flected rays could be caught up, they would only afford the appear- 
ance of a bright red glow, or, at the best, but a very confused and 
indistinct image of the fundus, owing to the insufficiency of the illu- 
mination and to the direction of the emerging rays. Eor in con- 
sequence of the optical condition of the eye, the incident rays, if 
the eye is accommodated for the object, are so reflected that they 
emerge again in exactly the same direction as they entered, and 
would, therefore, be brought to a focus at the point whence they 
originally emanated, that is at the source of light. The object and 
its retinal image are, in fact, in the position of conjugate foci. The 
pupil of the patient's eye will therefore appear black if it is accom- 
modated for the pupil of the observer, as the latter will then only 
see the reflection of his own pupil. 

A glance at Eig. 125 will readily explain this. If F is the object, 
and c its image formed upon the retina, rays reflected from c will be 
brought to a focus at E, so that whichever of these two points is 
the radiant-point, the other will be the focal point. Now, if we' 
place our eye at E, the luminous rays emanating from our pupil 
(which is black) willbe insufficient to illuminate the fundus of the 
patient, and hence his pupil will also appear black. 

But, in certain conditions of tbe eye, a considerable amount of 
reflection may be obtained, as, for instance, in the eyes of albinos, 



THE USE OF THE OPHTHALMOSCOPE. 313 

and in cases in which the retina is bulged forward by morbid pro- 
ducts. It is a well known fact that the pupil of the albino is mark- 
edly luminous. This is not caused, as is often supposed, by a 
greater reflection of the rays which enter the pupil, on account of 

Fig. 125. 



the deficiency of the pigment in the choroid, but is due to the great} 
amount of light which passes through the iris and sclerotic. The 
truth of this statement was proved by Donders, who placed before 
an albinotic eye a small screen, having a circular aperture for the 
pupil, but covering the iris and sclerotic in such a manner that no 
light could pass through them. It was then found that the pupil 
lost its luminosity, and at once acquired the usual darkness of other 
eyes. 

Again, if the position of the retina is altered, it being bulged 
forward by a tumor behind it (amaurotic cat's eye) or by fluid, more 
light will be reflected, and the fundus will appear luminous. More- 
over, on account of the more anterior position of the retina, the 
emerging rays will be divergent, and hence easily brought to a 
focus upon the retina of the observer. 

Briicke, in 1844-47, made a series of interesting experiments 
with regard to the luminosity of the eye, and showed that if the 
eye under examination is neither accommodated for the light nor 
for the pupil of the observer, but for some other nearer point, a por- 
tion of the light reflected from its background may be caught up 
by the observer, and the pupil will then appear red and luminous. 
This is shown in the preceding figure (Fig. 125). If F is a lumin- 
ous point for which the eye under observation (B) is accommodated, 
the rays emanating from F will be brought to a focus upon the 
retina at c, at which point a clear and distinct image of F will be 
formed. This being so, the rays reflected from c will unite at F, 
for F and c are conjugate foci. If the eye of the observer (A) be 
placed beside F, it will receive no luminous rays from B, and will 
hence see the pupil of the latter black. Now, if whilst the eye, B, 
remains accommodated for the luminous point, F, the latter is 
brought nearer to the eye, to F', the rays emanating from it will no 
longer be brought to a focus on the retina at c, but behind it, at d, 
and a circle of diffusion, a b, will be formed upon the retina. As the 
eye is accommodated for the distance, F, the rays emanating from 
the points of the circle of diffusion, a, b, will be brought to a focus 
at a' b', and there form an enlarged and inverted image of a b. 



314 THE USB OF THE OPHTHALMOSCOPE. 

Hence the eye of the observer, placed at A, will receive a portion 
of this reflected light, and therefore the pupil of B will appear more 
or less luminous. 

We shall see, hereafter, that Helmholtz turned this experience 
of Brlicke's to a practical use, and constructed his simplest, ophthal- 
moscope upon this principle. Before entering upon this, I must 
state that Helmholtz, in 1851, devised an apparatus by which the 
observer was enabled to place his eye in the direct line of the 
emerging rays, and thus gain a view of the fundus. The accom- 
panying figure and description of this instrument are from Mr. 
Carter's admirable translation of Zander's work on the ophthalmo- 
scope—a work I cannot too warmly recommend to all who wish 
to gain -a thorough knowledge of the theory of-the ophthalmoscope, 
its use in practice, and the different morbid changes of the fundus 
which may be recognized with it. The student will also derive 
great benefit from the perusal of Mr. Hulke's and Mr. Wilson's 
excellent works on the ophthalmoscope, which, though shorter and 
less exhaustive, yet contain a great amount of information^ con- 
veyed in a very clear and concise manner. 

" Under certain conditions, however, we may see the fundus of 
the human eye shine with a reddish lustre. Such conditions are 
shown in Fig. 126, where F is a luminous point, and S a polished 
plate of glass, which reflects the light a b falling upon it, into the 
observed eye B, in a direction as if it came from a point F' lying 
as far behind the plate S as the actual point F lies before it. 
Disregarding the loss of light caused by irregular reflection and 
other circumstances, the rays a d and b c, reflected from S, enter 
the observed eye, and become united at e. The emerging rays in 
their exit from B, must take precisely the same course as in their 
entrance ; they proceed, therefore, in the converging cone chad 
to the plate of glass, by which they are partly reflected back to F, 
while the remainder proceed in an unaltered direction forwards, 
to unite in a focus at F' and then again to become divergent. If 
now the eye of the observer be placed so as to intercept them 
before their uuion, as at A', it receives from e convergent rays 
that, made more convergent by its own refraction, are united 
before they reach its retina, upon which, after crossing, they form 
only the dispersion circle a' &'. The eye of A' Avould certainly, 
therefore, receive no image, but only the sensatiou of light — it 
would see the eye B illuminated, and the same would happen if 
it were so placed as to intercept the diverging rays behind the 
point F'. 

" After this principle was announced by Von Erlach, Professor 
H. Helmholtz, then of Konigsberg, and since of Heidelberg, was the 
first to discover the reason why the retina was not distinctly seen, 
and to find the means of rendering it visible. The problem was 
threefold : the observed eye must be sufficiently illuminated ; the 
eye of the observer must be placed in the direction of the emerging 
rays, and these must themselves be changed from their convergence, 
and rendered divergent or parallel. The solution of the main difli- 



THE USE OF THE OPHTHALMOSCOPE. 



315 



culty was obtained when, in a darkened chamber, the light of a 
lamp was allowed to fall on a well polished plate of glass in such a 

Fig. 126. 




After Zander. 



manner that the rays reflected therefrom entered the eye to be ob- 
served. The observer placed himself on the other side of the glass 
plate, and made the convergent rays divergent by a concave lens. 
Thus in Fig. 126 we place the concave glass c before the eye ot the 



S16 THE USE OF THE OPHTHALMOSCOPE. 

observer A, and convert the convergent pencil b gfa, coming through. 
S, into the divergent pencil # i kf, so that the eye A may form upon 
its retina e' a clear image of the point e. 

" The combination of such an illuminating apparatus with suita- 
ble lenses forms an instrument by which it is possible clearly to see 
and examine the details of the background of the eye of another 
person. To this instrument Helmholtz gave the name of Eye- 
mirror, or Ophthalmoscope." 

In order to obtain a better illumination Helmboltz afterwards 
employed three plates of glass instead of a single slip. A still 
greater advance was made when Helmholtz utilized Briicke's ex- 
periment above referred to, and employed a strong convex lens, 
held before the patient's eye, to converge the rays reflected from a 
large circle of diffusion formed upon the retina. In this way an 
enlarged and inverted image of the fundus was formed between the 
lens and the observer. This constitutes the " examination of the 
actual inverted image." 

Helmholtz placed the flame of a candle before the eye under ob- 
servation, and a screen behind the flame, so that the observer's eye 
could be brought close to the source of light, and thus catch the 
rays after they had been united by the convex lens, and formed an 
image of the fundus. This point of union lies at the focal distance 
of the lens. This mode of examination was, however, troublesome 
and inconvenient, and hence Ruete had recourse to a concave mirror 
having a central aperture for the observer's eye, and he thus still 
more increased the illuminating power. Since tben different forms 
of mirror have completely superseded the plates of polished glass. 

The following description and illustration from Zander clearly 
explain the action of the concave mirror in the inverted examina- 
tion, i. e., the use of a convex lens placed a short distance from the 
eye under observation, so as to converge the rays emanating from 
the circle of diffusion formed upon its retina. The patient is to 
accommodate for an infinite distance, so that the rays issue parallel 
from this eye. 

"Examination of the actual Inverted Image. — In Fig. 127 P is 
again the flame, S the mirror, L the convex lens, and B the eye 
observed. The rays a e bf, proceeding convergent from the mirror, 
and rendered more convergent by their passage through the lens, 
strike the cornea of B in c and d. Rendered still more convei'gent 
by the dioptric apparatus of B, they intersect at some point in front 
of the retina, for example at o, and form on the retina the dispersion 
circle a s. On account of the passive state of accommodation of the 
eye, the rays proceeding from it will follow courses parallel to the 
lines of direction a z and s x, and after their refraction by the lens 
L will unite to form at a d' an actual inverted image of a 3." 1 In 
this mode of examination it will be observed that the aerial image 
of the fundus is situated between the observer and the convex lens, 
and that it is inverted and enlarged. If we desire to increase the 

1 Carter's Translation of Zander, p. 20. 



THE USE OF THE OPHTHALMOSCOPE. 



317 



S L Ze ?I t ima £ e ' a somewhat weaker object lens (3| or 4" focus) 
should be employed, for as this renders the rays less conversing 
the image will be proportionately enlarged, but will at the same 
time he somewhat further from the eye ; this is, however, accom- 



Fig. 127. 




panied by the disadvantage that the field of vision is much dimin- 
ished in size. Hence the best plan is to use first a lens of 2 or 2\ 
inches focus, so as to gain a view of the whole fundus, and then to 
change this for a weaker lens if we desire to examine any special 
part of the background with particular care and minuteness. The 
size of the image may also be considerably magnified by placing a 
convex lens of 8 or 10 inches focus in the little clip behind the 
mirror. In this case the observer must, however, approach some- 
what closer to the patient. 

" In the examination of the virtual erect image the mirror alone is 
used, without the aid of an object lens, the observer approaching 
very closely to the patient's eye. He will thus obtain an erect, 
geometrical image of the fundus, the image being apparently 
situated behind the patient's eye, as in Fig. 128. ' E is the ex- 
amined eye, and E' the position of the examiner's eye ; r r are 
divergent rays from F, a flame, incident on the concave speculum 
A B, which reflects them convergingly as r' r' to E, about two 
inches distant, upon the fundus of which they form the circle of 
dispersion d d'. The rays reflected from any point a b within the 
circle, after leaving E, assume a direction parallel to the prolonga- 
tions of the lines a c b c (which pass through c, the optical centre 
of E) and reach the observer's eye at E', on the retina of which 
they form an inverted image of a b, which is mentally projected as 
the enlarged, erect, geometrical image a £." It will be explained 
hereafter that it is generally necessary to make use of an ocular 
lens behind the mirror, in order to gain a clear and distinct image 
of the fundus. The nature and strength of this lens depend upon 
the state of refraction of the eye of the observer and that of the 
patient. 

1 This figure and its explanation are from Mr. Hulke's able -work on the 
Ophthalmoscope. 



318 



THE USE OF THE OPHTHALMOSCOPE. 



Fig. 128. I must now pass on to a 

; brief description of the dif- 

ferent forms of ophthalmo- 
-*\P scope which are in most 

\ frequent use. For a full and 

I accurate description of the 

;« various kinds of ophthal- 

m moscope which have been 

!i\ invented, I must refer the 

reader to Mr. Carter's trans- 
lation of Zander. 

Ophthalmoscopes may be 
divided into four different 
classes : — ■ 

1. The portable or hand 
ophthalmoscopes. Of these 
I shall notice those of Lie- 
breich, Coccius, and Zehen- 
der [and Loring]. 

2. The fixed or stand 
ophthalmoscopes, such as 
Liebreich's and its excellent 
modification by Smith and 
Beck. 

3. The binocular ophthal- 
moscopes of G-iraud-Teulon, 
and of Laurence and Heisch. 

4. The aut- ophthalmo- 
scope. 

All ophthalmoscopes may 
also be divided into two 
principal classes, the homo- 
centric and the hetero-centric. 
In the homo-centric the mir- 
ror is concave, and its focus, 
calculated from its surface, 
is fixed and definite ; whereas 
in the hetero-centric the mir- 
ror is plane or convexj and 
the focus is negative, situ- 
ated behind the mirror, and 
can be altered according to 
the strength of the bi-convex lens which is fixed beside the mirror. 




1.— THE PORTABLE OR HAND OPHTHALMOSCOPES. 



(1.) The Ophthalmoscope op Liebreich. 

As has been already mentioned above, Ruete was the first to 
employ a concave perforated mirror (which was, however, fixed) 



THE PORTABLE OR HAND OPHTHALMOSCOPES. 319 



as a substitute for the slips of glass of Helmholtz, and this principle 

has formed the base for the numerous modifications at present in 

use. Of all the different forms of 

concave mirror I think Liebreich's Fig. 129. 

(Fig. 129) the most handy and useful. 

It consists of a concave metal mirror, 

about 1^ inch in diameter, and of 8 

inches focal length. Its centre is 

perforated by a small aperture, about 

1 line in diameter, the edges of 

which are exceedingly thin. The 

bronze back of the speculum around 

this opening is bevelled off towards 

the edge, so that the latter may be 

as thin as possible, in order that the 

peripheral rays of the cone of light, 

which passes through the aperture, 

may not be intercepted and cut oft* 

by a thick broad edge, which would give the opening the character 

of a short canal. Behind the speculum, which is fixed upon a 

short handle, is a small clip for holding a convex or concave lens. 




(2.) The Ophthalmoscope op Coccius. 

This instrument consists of a plane mirror combined with a lateral 
bi-convex collecting lens. Its chief advantages over the concave 
mirror are: that the observer's eye is placed within the cone of re- 
flected light, instead of being behind it ; that the focal distance ot 
the mirror can be altered according as the lens at the side is ap- 
proximated or placed further from the speculum, or as the power 
of the lens is changed ; the light can be more concentrated upon one 
point of the retina ; and the corneal reflex is far less. These advan- 
tages over the concave mirror are especially marked in the exami- 
nation in the direct image. With the concave mirror, only a cone 
of light corresponding in size to that of the pupil is admitted into 
the eye, and as the size of this cone diminishes with the approxi- 
mation, of the mirror, it follows that in the direct examination the 
illumination of the fundus is but slight. Moreover, on account of 
the very close proximity in which the mirror has to be brought to 
the patient's eye, much of the light from the lamp is often inter- 
cepted, whereas this is obviated by the collecting lens in Coccius's 
instrument. The latter is, therefore, to be much preferred to the 
concave mirror for the direct method of examination. For the in- 
direct method the advantages are less marked, but eveu for this I 
prefer it, for reasons which I shall mention hereafter. 

Coccius's ophthalmoscope (Fig. 130), as made at present, consists 
of a plane metal mirror, having a small central aperture. Behind 
the mirror is a hinged clip to hold a convex or concave lens. A 
lateral bi-convex lens of 5 or 7 inches focal length is held in a large 
clip mounted on a jointed bracket, which is so connected with the 



320 



THE USE OF THE OPHTHALMOSCOPE. 



neck of the handle that it permits of the lens heing moved to either 
side of the mirror. 

The original form of Coccius's ophthalmoscope [Fig. 131] differed 
from that which I have described above, and which is at present in 





general use, both in being square in 
shape, and in being made of glass in- 
stead of metal. The square mirror was 
inconvenient, and could not be steadied 
so well against the orbit as the circular. 
But the great disadvantage of the glass 
mirror was (as Helmholtz pointed out) 
that the aperture could not be bevelled 
down to so fine an edge as the metal 
one, in consequence of which more or 
less of a canal existed, which inter- 
cepted many of the peripheral rays, and 
produced considerable diffraction. 

The mode of using Coccius's ophthal- 
moscope is as follows: The collecting lens is to be turned towards 
the flame, which should be somewhat more than twice the distance 
of the focal length of the lens from the observer. The mirror is 
then to be set semewhat slanting to the lens and the eye of the 
patient. If the mirror is properly adjusted for the lens and the 
flame, we shall obtain, if we throw the image of the flame upon the 
palm of our hand or the cheek of the patient, a bright circle of 
light, with a small dark central spot, which corresponds to the open- 
ing in the speculum. The dark spot is then to be thrown into the 
pupil of the eye under examination, the surgeon placing the mirror 
close to his own eye, and looking through the aperture into the 
patient's eye, which should afford a bright luminous reflex. For 
the indirect mode of examination a bi-convex lens of from 2 to 3 
inches focus is to be held before the eye under observation. I, more- 
over, also use a convex lens of 8 or 10 inches focus behind the mirror, 
in order still more to magnify the image. If the direct examina- 



THE PORTABLE OR HAND OPHTHALMOSCOPES. 321 

tion is employed, a concave lens will generally be required behind 
the speculum. At first this instrument may be somewhat more 
difficult to use than the concave mirror, on account of our having 
to regulate the position of the collecting lens with respect to the 
name and the mirror ; but a little practice and perseverance will 
very soon overcome this difficulty. 

(3.) The Ophthalmoscope of Zehender. 

This consists in the combination of a slightly convex mirror with 
a bi-convex collecting lens. The illumination of the retinal image 
is thus greatly increased, for the whole of the cone of light reflected 
from the mirror can be collected into a narrower section, and can 
be thrown into the eye without the peripheral rays being inter- 
cepted by the edge of the pupil ; more light can also be diffused over 
the fundus, and it can be more strongly concentrated upon one 
point. 

This ophthalmoscope is, in fact, a modification of that of Coceius, 
and it very closely resembles the present form. Indeed, at the first 
glance, they may be readily mistaken for each other. On closer 
observation it will be, however, noticed, that Zehender's mirror is 
convex, whereas that of Coceius is quite plain. Moreover, on look- 
ing into Zehender's, we get a smaller image of our face than is the 
case with that of Coceius. It is certainly the best ophthalmoscope 
for the direct examination, but I prefer Coceius' for the indirect 
mode of observation. Indeed, the latter answers so well for both 
purposes, that for the general surgeon it will amply suffice. 

[(4.) The Ophthalmoscope op Loring. 

This instrument is extremely useful for the direct method of 
examination, as it avoids a constant change of lens behind the 
mirror, and expedites the determination of errors of refraction. 
It is so constructed 1 as to contain the requisite convex and concave 
glasses in three cylinders placed behind the mirror, and their rota- 
tion enables the surgeon to rapidly obtain the proper lens for his 
examination. Each cylinder is pierced for eight glasses, forming in 
the aggregate a series of lenses extending with but comparatively 
slight differences in focal value, from convex ? ' g to £ and from 
concave ? ' g to f. 

The manner in which the glasses are divided among the cylin- 
ders will be readily understood from the accompanying figures 
(Fig. 132). The first cylinder is made up entirely of convex glasses, 
by means of which all ordinary degrees of hypermetropia can with 
sufficient exactness be determined. One hole (0) is left vacant to 
represent emmetropia, without the necessity of removing the cylin- 
der, and for examination by the inverted image without an eye- 
piece ; should, however, the latter be desired, the observer has a 

' "Amer. Journal of Med. Sci.," April, 1870, p. 340. 
21 



322 



THE USE OF THE OPHTHALMOSCOPE. 
Fig. 132. 



Fiff. 2. 




Fig. I. Back of Loring's ophthalmoscope with cylinder in position. Fig. 2. Front View 
of instrument. Figs. 3 and 4. Remaining cylinders detached. Fig. 5. Astigmatic optometer 
and mirror. 

large selection at bis command. The second cylinder contains the 
concaves of moderate focal power, and the third is composed of 



THE FIXED OPHTHALMOSCOPE OF LIEBREICH. 323 

the high numbers, both positive and negative. These strong num- 
bers are designed for the determination of the highest degrees of 
errors of refraction and for the measurement of the inequalities of 
the fundus, such as excavations and elevations of the optic nerve, 
projections of tumors, retinal detachments, membranes in the 
vitreous, etc. 

The mirror being contained in a separate case is made detachable 
from the rest of the instrument, which can then be used as an 
optometer, the patient himself revolving the cylinder till the 
suitable glass is obtained. 

Besides the common concave mirror Dr. Loring has had another 
constructed which was originally designed for a stenopaeic slit to 
be used with the instrument when employed as an optometer for 
the determination of astigmatism. It consisted of a thin plate 
with a slit in it, whose length was equal to the diameter of the 
perforations in the cylinder. This was mounted like the mirror, 
and made to fit in the mirror cell in which it revolved, so as to 
allow the slit to correspond with any given meridian of the cornea. 
The meridian once determined, the patient turned the cylinder till 
the suitable glass was obtained. This plate was subsequently made 
with a polished surface in front, and then was made to serve also 
as a mirror for determining, by means of the ophthalmoscope, the 
amount of astigmatism in the principal meridians of the eye.] 



2— THE FIXED OPHTHALMOSCOPE OF LIEBREICH. 

This instrument is constructed upon the principle of the concave 
mirror as it is employed in the indirect mode of examination, and 
is so arranged that the whole apparatus (mirror and object lens) is 
fixed to a table, thus allowing the surgeon free use of his hands, 
and, when it is properly adjusted, enabling even an unskilled 
observer to see the details of the fundus. 

The instrument consists of two tubes, moving one over the 
other. That nearest to the surgeon has a small oblong portion 
cut out of its side, in order to admit the light to the concave 
mirror, which is attached to its extremity. Behind the speculum, 
there is a small clip for an ocular lens. The other tube carries, at 
its free end, a bi-convex object lens of from 2 to 2J inches focus, 
which is to be placed about 2| inches from the patient's eye. The 
two tubes are moveable, one upon the other, by a rack and pinion, 
so that the mirror and the object lens may be adjusted to any 
required distance. The whole apparatus is supported on an up- 
right stem, and may be fixed by a clamp to the corner of a table. 
This stem is also supplied with a moveable rest to receive the 
patient's chin, and thus to steady his head, which purpose is like- 
wise assisted by a small arc, supported by a rod adjusted to the 
upper end of the stem, the arc receiving the patient's forehead.^ 
Two small black shades are adjusted to the tubes, so as to cut off 
the light of the lamp from the eyes of the patient and the observer. 



324 THE USE OF THE OPHTHALMOSCOPE. 

The lamp is to be placed a few inches from the instrument, and 
nearly opposite to the opening in the tube containing the mirror, 
so that its rays may fall direct upon the latter. The patient is to 
be seated at the other end of the apparatus, having the eye under 
examination on a level with the object lens, and about 2| inches 
from it. Before illuminating his eye, it will be best to throw the 
light upon the palm of our hand, upon which it should form a 
bright circle of light having a small central dark spot ; if this is 
obtained, the instrument is properly adjusted, aud the light should 
be thrown into the patient's pupil, which should be widely dilated 
by atropine. If the reflection is not round, but jagged or faint, 
there is some fault in the adjustment of the lamp, mirror, or object 
lens, which must be corrected before the examination is commenced. 
If the reflections of the lamp on the retina confuse the image, the 
object lens should be slightly turned, so as to separate the two 
reflections and remove them from the centre of the field of view. 

This instrument is especially useful for demonstration to a class; 
or for the purpose of drawing the appearances of the fundus, as it 
leaves both hands of the surgeon at liberty. For common exami- 
nation it is too tedious and inconvenient, as we are completely 
dependent upon the patient, for the slightest movement of his eye 
will throw the object out of view, whereas with the hand ophthal- 
moscope we are chiefly dependent upon our own dexterity. 

A very excellent modification of Liebreich's instrument has 
been made by Messrs. Smith and Beck, as suggested by Mr. 
Kilburn. It is more easily adjustable, and its position with regard 
to the patient and observer can be more readily changed. Instead 
of being screwed on to the edge of the table, this instrument is 
fixed upon a small board supplied with rollers, which enables its 
position to be changed with great facility, and quite independently 
of the patient. Moreover, the standard carries a paraffin lamp, so 
that the position of the ophthalmoscope towards the light always 
remains the same, even although the former may be moved nearer 
to, or further from, the patient. This arrangement saves a great 
deal of time and trouble, and obviates the constant change of posi- 
tion between the lamp and the ophthalmoscope, necessitated by 
any movement of the latter. The rest which supports the patient's 
chin, instead of being attached to the instrument is independent 
of it, and is supported on a separate standai'd. This permits the 
position of the instrument to be changed without affecting that of 
the patient. 

Dr. Lionel Beale has devised a very ingenious ophthalmoscope, 
which can be used without darkening the room, aud which will 
be found especially useful in the light wards of a hospital, and in 
the physician's consulting room. I have been able to see the de- 
tails of tVie fundus perfectly with it by broad daylight. 

Dr. Beale has obtained this result by inclosing the reflector and 
lens in a tube, to the side of which is adapted a small paraffin 
lamp, with a large plano-convex lens. The illumination is so 
strong that it is not necessary for the tube to fit at all accurately 



BINOCULAR OPHTHALMOSCOPES. 



325 



to the margin of the orbit, and, indeed, the instrument can be used 
quite successfully even if two or three inches traversed by daylight 
intervene. The reflector is fixed in the tube at the proper angle, 
and the lens is made to incline a little, so as to remove the reflec- 
tions upon the retina out of the field of vision. With this instru- 
ment the optic disk is at once brought into view without any 
difficulty, and as the lamp moves with the mirror and lens, inex- 
perienced persons can use the apparatus successfully almost upon 
the first trial. The instrument weighs nearly a pound, but it can 
be made very much lighter. The lamp is the same as that which 
Dr. Beale has adapted to the hand microscopes he used for the 
demonstration of objects in his lectures. For making ophthalmo- 
scopic drawings, the instrument can be fixed to a pillar and stand. 
The artist can work in daylight with very little effort, while the 
patient can retain the eye fixed in the proper position without 
exertion. 

The instrument has been made by Mr. Hawksley, of Blenheim- 
street, Bond-street, who is now engaged in simplifying the arrange- 
ments, as much as possible, and in carrying out some improvements 
and reducing the weight of the metal work. Mr. Hawksley thinks 
the cost will be less than two guineas. 



3.— BINOCULAR OPHTHALMOSCOPES, Etc. 



"We are indebted for this valuable 
and ingenious instrument to Dr. G-i- 
raud-Teulon, who was the first to 
solve the difficult problem how it was 
possible to gain a binocular view of 
the details of the fundus, and thus 
give a stereoscopic effect to the 
image. 

The annexed diagram (Fig. 133) 
will explain its mode of action. Let 
be the eye of the patient, L the 
object lens, and m n, the concave 
mirror, having a central aperture. 
Behind the mirror are two rhombs 
(R R) of crown glass, ground so as to 
afford a double refraction at an angle 
of 45°. These rhombs are in contact 
at the edge o, thus equally dividing 
the aperture of the mirror. The ef- 
fect of this arrangement is that each 
pencil of rays, diverging from the 
actual image (a) of the background 
of the eye, after falling upon the 
mirror, is divided into two — a right 
and left half— and is then reflected 
by the opposite sides of the rhombs 
.in such a manner that it will emerge 



Fig. 133. 




After Girnud-Teulon. 



326 THE 'use of the ophthalmoscope. 

parallel to its original direction, and give rise to two inverted 
images d and g. The one (d) belonging to the right eye, the other 
(g) to the left. In order to cause these two images to become 
united, two decentrated lenses are adjusted behind the rhombs. 
The two image's d and g are consequently united at a', and the 
observer thus gains one stereoscopic view of the details of the fundus. 

The disadvantage of this ophthalmoscope, as originally con- 
structed, was, that as the rhombs were adjusted for a certain fixed 
distance, it only suited persons whose eyes were a corresponding 
width apart from each other; for if they were either nearer or fur- 
ther apart than the ocular openings, the surgeon either found that 
one eye was altogether excluded from participation in the visual 
act, or that he saw double. This difficulty has now been removed 
by a division of one of the rhombs into two parts, the outer of 
which is moveable, and thus allows of the instrument being adapted 
to all eyes. 

The mode of using this instrument differs somewhat from that of 
the ordinary monocular ophthalmoscope. Before attempting to 
use it, the observer should accurately adjust it for his eyes, so that 
when he is looking with both eyes at an object, he receives a single, 
clearly defined image. The readiest mode of adjusting the instru- 
ment is, to pull out to its furthest extent the screw at the end, 
which governs the position of the moveable half of the prism, and 
then to look through the ocular openings at the flame of the lamp 
placed at a distance of from 12 to 18 inches. If the observer only 
sees one image of the flame, he must alternately close each e3 r e, and 
notice whether the image remains apparent on the closure of either 
eye ; if so, the instrument is properly adjusted. But if the image 
disappears when the one eye is shut, it shows at once that the ob- 
server was only looking through one ocular opening, and that the 
position of the rhomb must be changed. If two images are seen, 
the screw must be gently pushed in (or out, as the case may be) 
until they are brought closer and closer together, and are at last 
fused into one clear and well defined image, which must remain 
apparent on the closure of either eye. The lamp is then to be 
placed directly behind the patient, so that its rays may pass over 
his head to the observer, who is seated straight before him. Before 
the examination is commenced, the surgeon should again convince 
himself of the proper adjustment of the instrument, by throwing 
the light into the pupil and noticing whether or not he sees one 
image of it, and whether this remains apparent when either eye is 
closed. At first, it is better to dilate the pupil with atropine, as 
this greatly facilitates the examination, for even to an accomplished 
ophthalmoscopist the binocular ophthalmoscope will prove some- 
what strange at the commencement, and will require to be used a 
few times before he becomes thoroughly familiar with it. In the 
more recent form of Giraud-Teulon's instrument, the mirror admits 
of a lateral movement, so that the lamp may be placed at the side 
of the patient. I, however, much prefer the illumination from 
above ; still this is not always convenient, and therefore it is neces- 



BINOCULAR OPHTHALMOSCOPES. 



327 



sary that the mirror should have a lateral movement, more espe- 
cially for the direct examination, which it renders more easy. 

A very excellent form of binocular ophthalmoscope has been in- 
vented by Messrs. Laurence and Heisch. [Fig. 134.] It consists 




of a set of prisms arranged so as to divide the rays into two. The 
two central prisms are fixed, but the two lateral ones are moveable 
in such a manner that they not only allow of a lateral movement, 
but their inclination can also be changed, so that the angle of di- 
vergence of the rays from the median line can be altered as may be 
necessary. On account of this arrangement, the decentred lenses 
of Giraud-Teulon are unnecessary, and instead of these, convex 
spherical lenses may be employed, and the image be thus consid- 
erably enlarged. 

" The instrument 1 consists of a horizontal metallic plate [A B] 
1J centimetre wide and 10 centimetres long, with a central per- 
foration. Behind this plate the central prisms [E E] are fixed, 
and the lateral ones [F F] slide in moveable settings, furnished 
with an index and graduated scale, by which their distance apart 
can be read oft' at a glance. Their inclination is regulated by a 
screw [G G] that acts upon both of them 
at once. The mirror [Kj turns upon a pin 
on the upper part of the plate, and the instru 
meat is completed by a moveable wooden 
handle. The metallic portions are con- 
structed of aluminium bronze, and the total 
weight is thus reduced to 2 ounces and 50 
grains. The case, as fitted up by Messrs. 
Murray and Heath, contains also an object 
lens, and two pairs of oculars, and is made of 
a shape and size convenient for the pocket." 

[The optical action of the instrument is 
represented in Fig. 135. " A and B 
are the extreme outer rays of a pencil pro- 
ceeding from a point (0) of the inverted 
image formed by the ordinary object lens; 
the ray B is reflected by the •prism B to 
the prism D, and hence to the observer's 
right eye placed behind D. Similarly, the 



[Fig. 135.1 
& 




1 Vide Carter's translation of Zander, p. 61. 



328 



THE USE OF THE OPHTHALMOSCOPE. 



ray A is reflected to the observer's left eye. He then sees two 
images of the fundus oculi. -By inclining the ocular prisms (D 
and C) inwards by the mechanism described at Fig. 134, the two 
images are fused into one." 

"The manner of using this instrument differs but little from 
that of using the ordinary ophthalmoscope, excepting that the 
light is placed above the head of the patient, and in the same 
vertical plane as that of the eye to be examined. (Fig. 136.) The 

Fig-. 136. 




observer holds the instrument horizontally, with the ocular prisms 
opposite his eyes, and reflects the light into the eye of the patient 
by tilting the mirror on its hinge ; in all other respects it is used 
as an ordinary ophthalmoscope."] 

This ophthalmoscope possesses certainly several advantages over 
that of Griraud-Teulon. In the first place, it is much lighter, which 
is very convenient if numerous cases have to be examined, for then 
a heavy instrument proves irksome and fatiguing. Again, on 
account of the alteration which can be made in the inclination of 
the prisms, the strain upon the internal recti muscles, in maintain- 
ing a forced convergence in order to unite the double images, is 
done away with. But this instrument is rather more apt to get 
out of order than that of Giraud-Teulon, if it be carelessly handled, 
as is apt to be the case in a class, where it is used by many different 
persons. 

The great advantage of the binocular ophthalmoscope consists 
in its affording us a stereoscopic view of the details of the fundus, 
so that they are brought into relief. We are thus enabled to judge 
of the real thickness of the retina, and can readily determine 



THE EXAMINATION WITH THE OPHTHALMOSCOPE. 329 



whether this is abnormally increased or diminished. The slightest 
degrees of detachment of the retina are also easily recognized. 
The optic disk shows itself in its reality, and we can detect at a 
glance whether its surface is level, arched forward, or excavated. 
Whereas, with the monocular ophthalmoscope, slight changes in 
the level of the disk are often very difficult to determine with 
certainty, even by an accomplished ophthalmoscopist. Again, we 
can ascertain with facility the exact position of extravasations of 
blood, exudations of lymph, or collections of pigment, and whether 
they are situated in the retina or the choroid, or perhaps in both 
these tissues. These points in the differential diagnosis are often 
of much importance in framing the prognosis. 

Various forms of aut-ophthalmoscopes, by which the surgeon could 
examine his own eye, have been devised, the first who succeeded 
in constructing such an 

instrument being Coc- F 'g- 137 - 

cius, since then Hey- a" %._ " 

m ami, Giraud-Teulon, 
and Zehender have in- 
vented different kinds 
of aut-ophthalmoscopes. 
The best and simplest of 
these is, I think, Giraud- 
Teulon's. Its action is 
explained by the accom- 
panying diagram (Fig. 
137), copied from Giraud- 
Teulon's article in the 
French translation of 
Mackenzie. The instru- 
ment consists of two plane 
mirrors m m', inclined to 
one another at an angle of 90°, and placed in front of the observer. 
A concave mirror (c t-') is held obliquely before the left eye (g), so 
that the rays from a flame (F) are reflected on to m, and thence on 
to m', which will reflect them into the right eye(d). A double 
convex lens I is placed between d and ?n', by which an inverted 
aerial image of A is formed, which is situated in reality at a' 
between the two mirrors, but which will appear to g to be situated 
beyond the mirror vi at a". In fact the rays emanating from d, 
instead of passing straight on, are bent twice at a right angle, and 
brought back to g, without having undergone any change in their 
relative positions. 




4.— THE EXAMINATION WITH THE OPHTHALMOSCOPE. 

In the selection of a portable monocular ophthalmoscope, our 
choice for the examination of the inverted image lies, I think, 
between the instruments of Coccius and Liebreich. The latter, 



330 THE USE OP THE OPHTHALMOSCOPE. 

on account of its being somewhat easier to use, is the one most 
generally employed. But as certain difficulties in the use of the 
ophthalmoscope have always to be overcome by beginners, I think 
it just as well that they should commence at once with the best 
instrument, even although the difficulty of the examination be 
thereby somewhat enhanced. I have for many years used Coccius' 
instrument for the inverted image, in preference to any other, as it 
possesses certain decided advantages over the concave mirror. 
Thus, on account of the lateral collecting lens, we can alter the 
focal length of the mirror and the intensity of the illumination to 
any desired extent, and we can also more fully concentrate the 
pencil of light upon any given portion of the fundus which we 
wish to submit to special examination. The corneal reflex is also 
much less, and this is of great importance if the pupil is very 
small, as is frequently the case in elderly people, in whom, with 
the concave mirror, we can often obtain, on account of the great 
corneal reflex, but a very imperfect view of the fundus without 
artificial dilatation of the pupil. 

Coccius' ophthalmoscope is also decidedly better than Liebreich's 
for the examination of the erect image, although it is for this pur- 
pose somewhat inferior to Zehender's. But to persons who desire 
to have only one ophthalmoscope, which shall serve them for all 
purposes, I should recommend that of Coccius, as fulfilling this 
desideratum better than any other. 

For conducting an ophthalmoscopic examination, a darkened 
room and a bright, steady -burning lamp are essentially necessary. In 
arranging a room for this purpose in a public institution, care must 
be taken that a bright stream of daylight does not enter directly in 
front of the patient, as this produces great reflection, weakens the 
illumination of the fundus, and renders the examination far more 
difficult, and needlessly trying to the eyes of the surgeon. 

The best gas-lamp for ophthalmoscopic purposes is that employed 
at Moorfields, which has an Argand porcelain burner, perforated 
by a number of small apertures, and closed underneath- by a very 
fine wire gauze, so as to regulate the draught, and thus steady the 
flame. The burner should not be too small, but should give a full 
round flame, as this affords a much better illumination than if the 
flame is long and thin. It is attached to a bracket, which admits 
of a universal movement in all directions. In the consulting room, 
a standard upright burner, connected with a gas pipe by means of 
an elastic tube, will be, however, perhaps more convenient. Or a 
good, bright-burning moderator lamp may be employed. The lamp 
or burner is to be covered only by a chimney, and not a globe. In 
order to decrease the intensity of the light, and thus to diminish 
the contraction of the pupil, a blue chimney may be employed, or 
what is still better, a blue object lens, as suggested by Mr. Carter, 
which is made by cementing a plane, light blue glass (A tint) be- 
tween two plano-convex lenses of the required power. 

It is best for the beginner to have the pupil widely dilated by 
atropine, as this greatly facilitates the examination. But when he 



EXAMINATION OF ACTUAL INVERTED IMAGE. 33 1 

has acquired some dexterity in the use of the ophthalmoscope, he 
must learn to examine with an undilated pupil, for the use of 
atropine proves very inconvenient to the patients. It should, there- 
fore, only be employed exceptionally, and when it is essentially 
necessary, as for instance when the pupil is very small, and the 
periphery of the fundus has to be examined for a suspected slight 
detachment of the retina, or morbid changes in the outlying por- 
tions of the choroid and retina. The examination in the region of 
the yellow spot is also very difficult, on account of the great reflec- 
tion of the light, and the great contraction of the pupil when this 
part of the eye is illuminated. If atropia is used, only a weak 
solution should be employed, otherwise the dilatation of the pupil 
will not only last some time, but there will also be much inconve- 
nience from the paralysis of the accommodation, which will, per- 
haps, prevent the patient from using his eyes for reading and 
writing for several days. For the purpose of simply dilating the 
pupil for ophthalmoscoping, a drop of a solution of 1 grain of atro- 
pine to 10 or 12 ounces of water will suffice to produce the requisite 
degree of dilatation in about an hour, and it will continue from 12 
to 30 hours. The atropinized gelatine disks will be found very 
convenient, as the patient can himself place one in the e} e, before 
his visit to the surgeon. 



5 THE EXAMINATION OF THE ACTUAL INVERTED 

IMAGE. 

The patient is to be seated on a chair, and the lamp should be 
placed beside, and somewhat behind him, at the side corresponding 
to the eye which is to be examined. The surgeon then seats him- 
self directly opposite to the patient, and, holding the mirror in his 
right hand, places it close before his eye, so that its upper edge rests- 
against the superior margin of the orbit. Then, turning the mirror 
slightly towards the lamp, he throws the reflection of the flame into* 
the eye, the pupil of which will be brightly illuminated. This- 
movement of the mirror must be very slight, and simply made by 
rotating the handle a very little between the Angers, otherwise the 
reflection will be thrown considerably above or to the side of the 
patient's head. The beginner always finds some difficulty in ac- 
quiring these slight movements of the mirror, as also the power of 
moving his own head in different directions, and yet constantly 
keeping the eye well illuminated. When the fundus is thoroughly 
lighted up, the rim of the bi-convex object lens is to be taken 
lightly between the forefinger and thumb of the left hand, and held 
about two inches from the eye under examination. The ring 
finger is to be placed against the upper edge of the orbit, in order 
to steady the hand, and this leaves the little finger free for lifting, 
the upper lid if necessary. [Fig. 138.] The object lens should be 
held at such a distance from the eye, that its focal length coincides 
with the pupil. A 2-inch lens should, therefore, be held a little 



332 



THE USE OF THE OPHTHALMOSCOPE. 



less than two inches from the cornea, and a 3-inch lens a little less 
than three inches. At first, some difficulty is always experienced 
in keeping the eye illuminated during the adjustment of the object 
lens, as the observer's attention is apt to be entirely directed to it, 

[Fig. 138.] 




and he forgets all about the illumination. Indeed one of the chief 
difficulties that the beginner has to overcome, is that of learning 
to work both hands readily together. 

When the fundus is well illuminated, we should first endeavor 
to gain a view of the optic disk, and the patient should therefore 
be -directed to look at the ear of the observer which is on the 
opposite side to the eye under examination, so that the optic axis 
of the latter may be turned somewhat inwards. Thus if the right 
eye is to be examined, the patient should look towards the sur- 
geon's right ear, and vice versa. For as the entrance of the optic 
nerve is not situated in the optic axis (centre of the retina), but 
towards its nasal side, it is necessary that the patient should look 
inwards, in order that the disk may be brought directly opposite 
to the observer's eye. To gain this position, the patient may also 
be directed to look at the uplifted little finger of the hand holding 
the ophthalmoscope. In this case its handle may be held horizon- 
tally, and the left hand used for holding the mirror when the left 
eye is under examination. It is still more convenient to have a 
screen or board, divided into differently-numbered compartments, 
placed at some distance behind the surgeon. The patient is then 
directed to look at a certain figure upon the board, according to 
the part of the fundus which we desire to examine. The object 



EXAMINATION OF ACTUAL INVERTED IMAGE. 333 

should always be placed at some distance, in order that the patient's 
accommodation may be relaxed to the utmost. The entrance of 
the optic nerve is readily recognized by its presenting a whitish 
reflex, instead of the red glare reflected from the fundus. As soon 
as this white reflex is obtained, the object lens should be adjusted, 
and we shall then have no difficulty in finding the optic nerve 
entrance, which appears in the form of a circular pinkish-white 
disk, on whose expanse are noticed numerous bloodvessels, which 
diverge from it to be distributed to different portions of the retina. . 
If the disk is not in view, it may also be easily found by tracing 
some of the retinal vessels up to the point towards which they 
converge — i. e., the optic nerve entrance. The disk having been 
found, the observer should very carefully study its color, the 
appearance of its surface and margin, and the course of the blood- 
vessels upon it, in order that these different points may be well 
impressed upon his memory. In the next place, passing from the 
disk, the different portions of the fundus should be successively 
examined, and the appearance and mode of distribution of the 
retinal vessels, and the difference between them and those of the 
choroid be carefully studied. The beginner should at first always 
examine a considerable number of healthy eyes, aud study very 
attentively the physiological appearances of the fundus, and the 
various peculiarities which may occur within normal limits. And 
then, when he has become thoroughly conversant with these 
diversities, he should pass on to the examination of the pathologi- 
cal conditions. The examination of the rabbit's eye, also affords 
excellent practice, and in the Albino rabbit the distribution of the 
choroidal and retinal vessels can be most beautifully seen. As the 
opportunity of examining a considerable number of human eyes is 
not always to be had, the following instrument, made by Wachet, 
of Paris, will be found extremely useful for practising ophthalmo- 
scopy, and for studying many of the morbid appearances of the 
fundus. It consists of an artificial eye, or dummy, made of brass, 
and fitted in front with a lens in the situation of the cornea. 
This lens is covered with a black metal cap, having a central 
aperture corresponding to the pupil. There are two of these caps, 
the one having a very small central opening corresponding to the 
normal size of the pupil ; the other a large aperture, like a widely 
dilated pupil. By changing the lens, we may convert the eye into 
a hypermetropic^ myopic, or astigmatic one. The posterior half of 
the eye opens, so as to admit of the insertion of a papier mache" 
cup or disk, colored to represent the appearance of a healthy 
fundus, or of some pathological condition, as for instance, retinitis 
pigmentosa, excavatiou of the optic nerve, posterior staphyloma, 
etc. In the box containing the instrument, there is a series of 
these colored disks, illustrating many of the morbid ophthalmo- 
scopic appearances of the fundus. The eye is fixed upon a standard 
for placing it upon a table. It is termed Perrin's artificial eye. 

I have already mentioned, that if we desire to increase the size 
of the image in the indirect mode of examination, we must em- 



834 THE USE OF THE OPHTHALMOSCOPE. 

pipy a weaker object lens, e.g., of 3 or 4 inches focus which must 
be held somewhat further from the eye. In order to magnify the 
image still more, Coccius 1 has devised a compound object lens 
which consists of two convex lenses (one of which has a focal 
length of 2, the other of 2\ inches), inserted in the extremities of 
a brass tube, composed of two portions, each of which is 1\ inches 
in length, and made to slide, one within the other. The effect of 
this is, that parallel rays reflected from an emmetropic eye will be 
united within the tube into an actual inverted image, the rays 
from which will then pass through the second lens, which will 
afford a magnified virtual image of the actual image within the 
tube. The disadvantages of this compound object lens are, that it 
is expensive, and very cumbersome, proving very fatiguing, if 
many patients have to be examined in succession. I find, more- 
over, that we may gain almost as great an enlargement, by using 
an ordinary object lens of four inches focus, and a convex lens of 
eight inches focus behind the mirror. 



6.— THE EXAMINATION OF THE VIRTUAL ERECT IMAGE. 

It has already been stated, that in this mode of examination the 
observer must go very close to the patient's eye. The lamp must 
therefore be placed on- the side corresponding to the eye under 
examination, and the surgeon will find it most convenient to ex- 
amine with his right eye the corresponding eye of the patient, and 
vice versd. For the examination of the erect image the ophthalmo- 
scope of Coccius or Zehender will be found preferable to that of 
Liebreich. Not only is the illumination better, and the corneal 
reflex considerably less, but it is also easier, on account of the 
lateral collecting lens, to maintain a good illumination of the eye, 
and to keep the optic axis of the observer's eye in a line corre- 
sponding to that of the patient, which is often difficult, if the 
mirror has to be considerably turned in order to catch the rays 
from the lamp. If the surgeon is not much accustomed to this 
mode of examination, and the pupil is small, the latter should be 
dilated with atropine, for this will increase the size of the field of 
vision, and facilitate the lighting up of the fundus. If the observer 
and the patient are both emmetropic, and their accommodation is 
suspended (i. e., if they are, accommodated for their far point, in this 
case for parallel rays) the surgeon will receive a clearly defined and 
distinct image of the details of the fundus. The beginner, how- 
ever, generally finds considerable difficulty in completely relaxing 
his accommodation, more especially as his close approximation 
to the patient leads him involuntarily to accommodate for a point 
considerably nearer than his far point, i. e., he is accommodated for 
more or less divergent rays. This will render the image indistinct, 

1 Mr. R. B. Carter has given an excellent description of this apparatus and its 
mode of action in the " Lancet," March 18, 1865. 



EXAMINATION OF VIRTUAL ERECT IMAGE. 335 

and necessitate the use of a concave ocular lens, in order to give 
the requisite degree of divergence to the parallel rays emanating 
from the patient's eye. In certain conditions of the refraction- 
either of the patient's or surgeon's eye, a concave ocular lens is 
absolutely necessary to render the image of the fundus distinct. 
Thus, if the patient's eye is emmetropic, but that of the surgeon 
myopic, the rays from the former will be parallel, and be conse- 
quently brought to a focus in front of his retina, and a concave 
lens will be required to give them the necessary degree of diver- 
gence. The strength of this lens should be such as'to neutralize 
his niyopia for distance. A still stronger concave lens will be 
required, if the eyes of the surgeon and "patient are both myopic, 
for then the rays will impinge in a convergent direction upon the 
surgeon's eye. But if the surgeon is myopic, and the patient 
hypermetropic, the former may be able to see the fundus distinctly 
without the aid of a concave lens, for the following reason: the 
focus of the dioptric system of the eye under examination, will in 
this case lie behind the retina, and the eye will therefore be ad- 
justed for 'more or less convergent rays. The emerging rays will 
consequently be divergent, and will be readily united upon the 
observer's retina, if his myopia is not too considerable in degree. 
The same will occur if the surgeon is hypermetropic or emmetropic, 
but then he will have to use his power of accommodation, in order 
to bring the divergent rays to a focus upon his retina. If, on jtho 
other hand, the observer is hypermetropic, he may also be able to 
examine a myopic or emmetropic eye (if the myopia is not too 
great) without the aid of a concave lens, for he will be able to unite 
convergent rays upon his retina, and also parallel rays by an effort 
of the accommodation. The cases containing the portable oph- 
thalmoscopes are supplied with a series of concave ocular lenses, 
varying in focal length from 4 to 10 or 12 inches, and fitting into 
the clip behind the mirror. The surgeon should select the strength 
of the lens according to the state of the refraction of his own and 
the patient's eye. 

The chief advantage of the erect image is, that we obtain a 
much larger image, so that the minute details of the fundus can 
be studied with much greater accuracy. This mode of examination 
is therefore of much importance in solving any doubts which may 
exist with the reverse image, as to the exact nature or situation of 
any morbid appearances. But the field of vision is more limited, 
and the examination somewhat more difficult. Moreover, it is not 
always convenient or agreeable to examine all patients in such 
close proximity. The latter may be one reason why this mode of 
examination is far too much neglected in England in favor of the 
inverted image. As a rule, it is best to obtain a general view of 
the appearances of the fundus in the inverted image, and then, if 
we desire to examine any particular point with greater minuteness 
and accuracy, to have recourse to the direct method. 



336 THE USE OF THE OPHTHALMOSCOPE. 



1.— THE OPHTHALMOSCOPIC APPEARANCES OF 
HEALTHY EYES (Plate I, Figs. 1 and 2). 

Before commencing any ophthalmoscopic examination of the 
fundus, the condition of the cornea, iris, pupil, and crystalline lens 
should be examined by the oblique illumination. This having 
been done, the same structures should be viewed by transmitted 
light, i. e., the surgeon should examine the eye by the direct 
method (without the interposition of a convex lens between the 
mirror and the patient's eye), but the mirror should be held at 
some distance (14 or 18 inches) from the eye under examination. 
In this way no opacity of the refracting media can escape detection, 
which is not unfrequently the case if these modes of examination 
are neglected, and the fundus only examined with the inverted 
image. We can also in this way readily ascertain the state of 
refraction of the eye. 

The examination of the refracting media in a healthy condition, 
of course, affords a negative result. Sometimes small flakes of 
mucus may be noticed on the cornea, giving it a somewhat irregu- 
lar appearance. They disappear on closure of the lids. 

It has been already stated (p. 241) that certain physiological 
changes occur in the lens in advancing age, and we must be upon 
our guard not to mistake these for commencing cataract. The 
lens substance becomes thickened and consolidated, and the nucleus 
assumes a yellowish tint, which is especially apparent by reflected 
light. Indeed this opacity is sometimes so considerable, that it 
may be mistaken for a tolerably advanced cataract, but on exa- 
mining the lens by transmitted light (with the mirror only) it will 
be found perfectly transparent, and the details of the fundus quite 
distinct. 

On the other hand, the healthy appearances presented by the 
fundus oculi deserve and demand the closest and most attentive 
study, in order that the many diversities which they may present may 
not be mistaken for morbid phenomena. It is only by an intimate 
knowledge of the many physiological peculiarities which may 
exist in a perfectly normal eye, that we can avoid committing 
grave errors in diagnosis. Beginners are but too apt to hurry over 
the examination of healthy eyes with a careless, "Oh, there is 
nothing the matter; the fundus is quite healthy," craving only 
after the most marked pathological changes, such as large posterior 
staphylomata, very deep excavations of the optic nerve, and huge 
patches of atrophied choroid ; and completely overlooking the 
minuter shades of difference between a healthy and morbid con- 
dition of the fundus, a knowledge of which proves of the greatest 
importance in practice. 

On looking at No. 1 of the ophthalmoscopic plates, the reader 
will be at once struck by the marked difference in the appearances 
presented by Figs. 1 and 2, and yet both illustrate a perfectly 
healthy fundus. 



OPHTHALMOSCOPIC APPEARANCES. 337 

In Fig. 1 (which is taken from a person with black hair and a 
dark-brown iris) the optic nerve entrance appears circular, and of a 
yellowish-white tint. The bloodvessels emerge somewhat to the 
left of the centre of the disk, which is here of a deeper white. 
The paler vessels are the retinal arteries, the darker ones the veins. 
They pass over the disk to the retina, where they course and divide 
in different directions, chiefly upwards, downwards, and towards 
the left. At some little distance to the right of, and slightly 
below, the disk, is noticed a large dark-red spot, with a small 
white dot in the centre. This is the macula lutea, or yellow spot, 
with its foramen centrale. It will be observed that the vessels 
course round the yellow spot, leaving it free. The fine gray film 
in the region of the disk and the yellow spot is due to the reflex 
yielded by the retina ; it is only observable in dark eyes, and is 
consequently altogether absent in Fig. 2. The fundus of the eye 
is of a rich dark-red tint, and only the retinal vessels are apparent, 
those of the choroid being hidden by the density of the pigment 
in the epithelial layer and stroma of the choroid. 

In Fig. 2 (taken from the eye of a person with very light hair 
and a blue iris) the appearances are quite different. The disk is 
of a more rosy tint, the retinal vessels, although very distinct, are 
less markedly so than on the darker background of Fig. 1. The 
region of the yellow spot is of a bright red color, and the foramen 
centrale appears in the form of a little light circle. But the 
greatest difference is noticed in the pale, brilliantly red color of 
the fundus, and the distinctness with which the finest branches of 
the choroidal vessels can be traced. The ciliary arteries enter in 
the region of the yellow spot, and, running towards the periphery, 
ramify in various directions, and partly pass over directly into the 
larger branches of the vasa vorticosa, situated at the equator of 
the eye. 

The red color of the background of the eye, as seen with the 
ophthalmoscope, is due to the reflection of the light from the blood- 
vessels of the retina and choroid, more especially the latter. As 
the retina is very translucent, but little light is reflected by it, and 
the sclerotic can only be seen through the choroid, and will there- 
fore be the more apparent the less pigment there is in the latter. 
The appearance presented by the fundus will, therefore, vary 
greatly according to the degree of pigmentation of the choroid. 
If its epithelial layer and stroma are darkly pigmented, the vessels 
of the choroid may be completely hidden, even at the periphery of 
the fundus. But if the epithelial layer contains but little pigment, 
and the stroma is, on the other hand, richly pigmented, the cho- 
roidal vessels will appear like bright red bands or ribbons, divided 
by dark islets or intervals, the so-called intra-vascular spaces. 
These vessels are chiefly situated in the stroma of the choroid, for 
they are less covered by the pigment than those of the vense vorti- 
cosae, which lie deeper (nearer the sclerotic), or the smaller vessels 
(Schweigger). The intra-vascular spaces are of a longitudinal 
shape near the equator of the eye, and more oval or circular in the 
22 



338 THE USE OF THE OPHTHALMOSCOPE. 

vicinity of the disk. If the stroma is light, and the epithelium 
but moderately pigmented, the epithelial- cells may be well seen 
with a considerable magnifying power, as has been shown by 
Liebreich, and may be recognized as small circumscribed dots 
uniformly studded over the fundus, giving it a markedly granular 
appearance. In eyes in which the pigmentation of the choroid is 
but very slight, the choroidal vessels may be most beautifully 
traced to their smallest divisions, as also the large stems of the 
vense vorticosse as they perforate the sclerotic. The red color of 
the background is also influenced by age and the illumination. 
It is of a brighter tint in young persons than in older individuals. 
If the illumination is strong, the brightness will be uniform, if it 
is weak, it will decrease from the disk towards the periphery of 
the fundus. 

The retina is extremely translucent, and reflects but little light. 
On this account it is not visible in light eyes, but becomes so when 
the fundus is dark, appearing like a thin gray film or halo over 
the background. In very dark eyes, such as those of negroes, the 
retina is very distinctly apparent, showing a gray striated appear- 
ance, especially in the vicinity of the disk. These striae are not, 
Schweigger thinks, due to the nerve fibres, but to the peculiar 
arrangement of the connective tissue. 



8.— THE OPTIC DISK. 

The normal disk is subject to numerous and sometimes marked 
differences in shape, color, and size. An exact knowledge of all 
the peculiarities which come within the normal and physiological 
standard is absolutely necessary to prevent the surgeon from fall- 
ing into errors in diagnosis, and mistaking some perfectly physio- 
logical appearances as being of pathological import. 

The entrance of the optic nerve is generally round, but not per- 
fectly circular ; it is often oval, having the long diameter vertical. 
This oval appearance is particularly striking in cases of astigmatism. 
The disk is generally of a transparent, grayish-pink tint, with a 
slight admixture of blue. This tint varies in appearance with the 
pigmentation of the choroid ; thus in dark eyes the disk appears 
white and glistening, whereas in very light eyes it assumes a more 
rosy hue. The admixture of the color of the optic nerve entrance 
is made up from three sources ; the white is due to the reflection 
from the connective tissue of the lamina cribrosa, the red to the 
blood in the capillaries on its expanse, and the bluish-gray to the 
nerve tubules lying in the meshes of the cribriform tissue. The 
outline of the disk appears sharply defined, but on closer observa- 
tion we notice that it may be divided into an internal gray ring, 
the real boundary of the nerve ; outside this, is the white line of 
the sclerotic ring, which varies somewhat in size, being broadest 
and most apparent at the outer side of the disk. External to the 
scleral zone, is the dark-gray line of the opening in the choroid. 



THE OPTIC DISK. 339 

This choroidal ring is somewhat irregular in shape and color, being 
most marked at the outer side, at which there is often a well-de- 
fined deposit of pigment molecules, assuming the appearance of a 
broad black crescent, which is frequently mistaken by beginners 
for some pathological change. 

The retinal vessels generally emerge from the central portion of 
the disk, or somewhat to the inner side of it. If the division of 
the central artery takes place after its passage through the lamina 
cribrosa, the division of the main trunk into the different branches 
can be distinctly observed. Whereas, if the division occurs before 
the passage of the trunk through the lamina cribrosa, the main 
branches pierce the disk in an isolated manner, so that their point 
of division from the trunk cannot be distinguished. The number, 
mode of division, and course of the retinal vessels vary very con- 
siderably, being constant only in this, that the principal branches 
run upwards and downwards. As a rule, no main branch runs 
inwards, but only a considerable number of smaller vessels; whereas 
towards the outer side only a few very small, short twigs are sent. 
The most frequent arrangement is, that an artery and two veins 
pass upwards, and the same downwards ; but sometimes there are 
two arteries and two veins. The arteries may be readily dis- 
tinguished from the veins by being lighter in color, smaller, and 
straighter in their course. Moreover, along the centre of the vessel 
is noticed a bright streak. Various opinions have been advanced 
as to the cause of this central white stripe. Von Trigt and Jaeger 
originally explained it thus: That the rays of light which fall 
perpendicular upon the cylindrical walls of the vessel are reflected 
in a perpendicular direction ; whereas the rays which fall external 
to the centre of the vessel are reflected laterally, and hence cause 
the sides to appear dark. This explains the reason why the white 
stripe varies in position according to that of the visual line of the 
observer, for if we look at the side instead of the centre of the 
vessel, the light stripe will also shift to the side. More recently, 
Jaeger has given up this opinion, and believes that the column of 
blood within the vessel and not the walls of the latter produce the 
reflection. 1 Loring, on the other hand, believes, 2 '' that the light 
striking the wall nearest the observer passes through this on ac- 
count of its transparency, without being reflected to any appreciable 
degree, traverses the contents of the vessel, and is then reflected 
back slightly from the opposite wall, but principally from the sub- 
jacent tissues." This view has been again opposed more recently 
by Schneller, 3 who maintains that the light streak is due to the 
reflection of light from the anterior wall of the artery. The retinal 
veins are of a darker tint, larger, and more undulating than the 
arteries. On account of the greater tenuity of the walls of the 
veins, and of the blood-tension being less in them than in the 

1 " Ophtlialmoscopischer Hand. Atlas," 1869, p. 32. 

2 "Trans, of American Ophthaknological Society," 1870, p. 122 ; also Knapp's 
"Archiv.," ii. 1, 199. 

3 "A. f. 0.," xviii. 1, 113. 



340 THE USE OF THE OPHTHALMOSCOPE. 

arteries, they are somewhat flattened and not cylindrical in form. 
Hence the reflection of light is very slight, and the central bright 
streak hardly observable. Even on the normal disk the sheath of 
the vessels is sometimes apparent, giving rise to a double contoured 
white stripe at the edge of the principal vessels, arteries, and veins. 
This is generally confined to the disk and its immediate vicinity 
(Mauthner). The blood supply of the most anterior part of the 
optic nerve is maintained not only by the small twigs given off to 
it from the central vessels of the retina by the vessels of the 
external and internal sheath, but also by a series of branchlets 
emanating from a vascular circle, which is situated close to the 
edge of the optic nerve, and which is formed by three or four of 
the short posterior ciliary arteries. 1 Leber, moreover, has found 
that numerous arteries and some veins also pass directly from the 
choroid to the optic nerve, anastomosing there with the network 
of vessels which surrounds the nerve fibres. 2 

On closely regarding the surface of the disk, we notice that its 
color varies at different points, and that it presents, moreover, 
towards the outer side, a somewhat mottled grayish-white appear- 
ance. This gray stippling is produced by the nerve tubules seen 
in section, and the white dots or lines between them are due to the 
trabecule of the sieve-like lamina cribrosa. At the point of exit 
of the retinal vessels the white appearance is very marked, and 
often presents a little pit or hollow. Whilst the outer portion of 
the disk presents a mottled grayish-white appearance, the inner 
half assumes a much redder tint. The reason of this is easily 
explained. As a greater number of the optic nerve fibres, after 
the entrance of the optic nerve into the eye, bend over to the 
inner side, the transparency of this portion of the nerve is much 
diminished by this close super-imposition of the fibres, and hence 
the details of the lamina cribrosa are hidden. Whereas on the 
outer half, the latter are still very evident, as the layer of nerve 
fibres is here much less considerable and more arched upwards and 
downwards, and the white reflection consequently much more 
marked. Inattention to these facts may lead the observer into 
considerable errors of diagnosis. He may consider the normal red- 
ness of the inner half of the disk as pathological, and assume the 
presence of hypersemia, or even inflammation of this part of the 
nerve ; or he may mistake the white appearance of the outer half 
for commencing atrophy. 

We must now notice two peculiarities of the optic disk which 
are often met with in perfectly healthy eyes, viz., 1, spontaneous 
or easily producible pulsation of the retinal veins; 2, physiological 
excavation of the optic nerve. 

The venous pulsation is characterized by an alternating increase 

i Vide Jager, "Einstellung dea dioptrischen Apparates," p. 55; also Leber, 
"A. f. O.," xi. 1, 5. 

2 Galezowski's opinion that the minuter vessels of the disk, through which the , 
latter obtains its reddish tint, are not branches of the central vessels of the retina, 
but of the vessels of the pia mater and brain, is disproved by Leber, "A. f. O.," 
xviii. 3, 25 ; vide also Dr. Wolfring's article, ib., p. 10. 



THE OPTIC DISK. 341 

and diminution in the calibre of the vein. The emptying of the 
vein commences at the centre of the optic disk, and extends to the 
periphery; the refilling, on the other hand, begins at the periphery 
and extends towards the centre. The venous pulsation is gene- 
rally only visible in the expanse of the disk, but in very rare cases 
it may even extend beyond its margin. It exists probably in all 
eyes, but does not generally appear spontaneously. The pulsation 
may, however, be made apparent, or rendered more marked or 
distinct, by slight pressure with the finger upon the eyeball, and 
we may thus alternately produce a complete emptying and refilling 
of the vein. On a sudden relaxation of pressure which has been 
continued for a little time, the veins become rapidly overfilled and 
swollen, this dilatation lasts for about a minute, and then they 
resume their normal calibre. The respiration also somewhat affects 
the retinal circulation ; thus, an increase in the size of the vein 
may be noticed during strong expiration, whereas a deep inspira- 
tion causes it to diminish. The vein and artery are in an opposite 
state of fulness, the arterial systole being synchronous with the 
venous diastole. 

Whilst spontaneous pulsation of the retinal veins is a perfectly 
physiological phenomenon, this is not the case with the arterial pul- 
sation, for this generally only exists when the intra-ocular tension 
is abnormally increased. It is, therefore, a symptom of great im- 
portance in the diagnosis of a glaucomatous condition of the eye- 
ball. 1 The presence of venous pulsation was supposed to indicate 
a fluctuation in the intra-ocular pressure, but according to Me- 
morsky 2 this is not so. He considers it to be a visible expression 

1 It is a very interesting and important fact that in eases of insufficiency of the 
aortic valves there is marked spontaneous pulsation of the retinal arteries. This 
was first pointed out by Dr. H. Quincke ("Berliner Klinische Wochenschrift," 
1868, No. 34), but was also discovered independently by Professor Becker, who 
has made very extensive and valuable researches upon the subject (" Kl. Mo- 
natsbl.," 1871, p. 380, and "A. f. 0.," xviii. 1, p. 206). This pulsation, though most 
marked on and near the disk, extends far into the retina. Sometimes it is only 
occasionally present, but is always increased by any excitement or acceleration of 
the heart's action. Becker observed it in all cases of insufficiency of the aortic 
valves, which were uncomplicated with lesions of the other valves ; the pulsations 
being the stronger and the more observable the more the accompanying hypertrophy 
of the left ventricle was developed. Only in those cases in which, together with the 
aortic valvular affection, there was great anaemia or fatty degeneration of the heart, 
there was no pulsation. In some rare instances there is also a systolic reddening 
and diastolic blanching of the disk, which appears to be due to a capillary pulsation 
in the disk. These pulsations are best seen in the erect image ; indeed, the capil- 
lary pulsation is only thus visible. This spontaneous arterial pulsation " does not 
resemble the so-called arterial pulsation as it occurs in glaucoma. Whilst the latter 
is only an intermittent influx of arterial blood into the eye, the former reveals to the 
eye all the individual qualities, which the finger is able to distinguish in the radial 
pulse. We can count the frequency of the contraction of the heart, we recognize 
the widening and elongation of the arterial tube (greater and lesser pulse) ; we can 
also distinguish how great apart the expansion of the artery, its contraction (zusam- 
mensinken), and the pause take in the duration of a complete pulse-wave (pulsus 
celer et tardus). We can therefore observe direot with the ophthalmoscope the un- 
dulations of the pulse-curve." " Kl. Monatsbl.," 1871, 381. Often there is also 
very marked spontaneous venous pulsation. 

2 "A. f. 0.,"xi. 3, 107. 



342 THE USE OF THE OPHTHALMOSCOPE. 

of the action of the forces which regulate the blood-pressure within 
the eye. 

The physiological excavation may be known by its being limited 
to the central portion of the disk ; it is, moreover, generally very 
small and shallow, and may continue throughout life without un- 
dergoing any change. Sometimes the excavation is well marked 
and easily recognizable, the central portion of the disk presenting 
a peculiar white, glistening appearance, of varying size and form. 
This central, glistening spot may be oval, circular, or longitudinal, 
and its size is generally very inconsiderable in comparison with 
that of the disk ; it is surrounded by a reddish zone, which may 
be almost of the same color as the background of the eye. The 
width of this zone varies with the extent of the excavation ; if the 
latter is small, the zone will be very considerable, but if it is large, 
the zone will be narrow, and limited to the periphery of the disk. 
The edges of the cup are generally slightly sloping, and never 
abrupt or steep, so that the excavation passes over gradually into 
the darker zone without there being any sharply-defined margin. 
But if the excavation is conical or funnel-shaped, the edges are 
more abrupt, and the margin more defined. On tracing the retinal 
vessels from the periphery towards the centre of the disk, we no- 
tice that they undergo peculiar changes when they arrive at the 
margin of the excavation, for instead of passing straight on, they 
describe a more or less acute curve as they dip down into it. 
This curve may be very slight and gradual if the cup is shallow, 
but if it is deep and extensive the curve may be abrupt and give 
rise to a displacement of the vessels at its edge. In the expanse 
of the excavation, the vessels generally assume a slightly darker 
shade, but they sometimes appear of a lighter and more rosy tint, 
and seem to be enveloped by a delicate veil. The excavation is 
frequently not in the centre of the disk, but nearer its outer 
side. A very peculiar appearance is produced, if a glaucomatous 
excavation occurs in a nerve having a physiological cup, for then 
the two conditions may for a time exist side by side ; the physio- 
logical excavation is, however, subsequently merged in the deeper 
glaucomatous cup. 



9.— THE OPHTHALMOSCOPIC EXAMINATION OF 
DISEASED EYES. 

The Refracting Media. 

Before commencing any ophthalmoscopic examination of the 
fundus, the refracting media should always be examined by the 
oblique illumination and by transmitted light (vide p. 336). By 
making this a constant rule, the beginner will avoid falling into 
many an error m diagnosis which might otherwise occur, such as 
mistaking opacities of the cornea, the capsule, or the lens for some 
deeper-seated lesion. In making an examination of the lens or the 
vitreous humor the pupil should be widely dilated, although an 



OPHTHALMOSCOPIC EXAMINATION. 343 

expert observer will often be able, even with an undilated pupil, to 
detect opacities which are situated at the margin of the lens, or the 
periphery of the vitreous humor, by making the patient look very 
far in the opposite direction, which will enable the surgeon to look 
quite behind the iris. The color of opacities in the refracting media 
will .vary according to the amount of illumination, and the fact 
whether they are examined by reflected or transmitted light. In 
the former case, they will appear in their true colors, the fundus 
being in the shade, so that they will look like gray or whitish 
opacities situated upon a dark background. It is different, how- 
ever, when the fundus is lighted up with the ophthalmoscope, for 
then the opacities will appear like dark specks, of varying size and 
form, upon a bright red background, for their surfaces can reflect 
but little light, and they are thus seen in shadow. On this account, 
very small opacities are best seen by a weak illumination, for in 
consequence- of their very slight reflection, they become invisible if 
the illumination is too bright. It is of much importance to be 
able rightly to estimate the depth at which any opacity in the re- 
fracting media is situated. There cannot be the slightest difficulty 
about this when the opacity is in the cornea, the capsule, or the 
anterior portion of the lens, for with the oblique illumination we 
shall be able to ascertain the position of the opacity in relation to 
the pupil. Indeed, for opacities in the anterior half of the eyeball 
the oblique illumination is of most service, but for those in the 
posterior half the ophthalmoscope should be used. But it is best 
to avail ourselves of both modes of examination. When the opacity 
is situated in the vitreous humor, it is more difficult to ascertain its 
exact depth. The two following methods of examination will, how- 
ever, enable us to decide this : If, for instance, the observer (using 
the direct method) looks in such a direction that his visual line 
passes through the turning point of the patient's eye, it will be 
found that this point and the corneal reflection of the mirror will 
alone remain stationary when the eye is moved in different direc- 
tions. Any opacity which is situated in front of this point will 
move in the same direction as the cornea, whereas any opacity 
situated behind the turning point will move in a direction opposite 
to that of the cornea. The further the opacity is from the turning 
point of the eye, the greater will its excursion be. ]S~ow the turn- 
ing point corresponds as nearly as possible to the posterior pole 
of the crystalline lens. If there should consequently be an opacity 
situated at this spot (posterior polar cataract), it will remain sta- 
tionary during the various movements of the eye. If the opacity 
is situated in front of the posterior pole, it will move in the same 
direction as the cornea, if the latter moves upwards the opacity 
will do the same ; the reverse will occur if the opacity is situated 
behind the turning point, for then it will move downwards as the 
cornea moves up, and vice versd. 

It is more difficult to determine the exact position of the object 
when it lies very close to the retina. This is best done by the 
surgeon making a slight movement with the object lens (in the ex- 



344 ' THE USE O.F THE OPHTHALMOSCOPE. 

amination with the reverse image), his own and the patient's eye 
being at the same time kept stationary. The nearer that the object 
is to the observer, the more marked will be its movement in the 
same direction as the lens. To illustrate this, Liebreich 1 cites the 
following example : If we suppose that a filiform opacity were to 
extend from the posterior pole of the lens to the centre of the retina, 
it would appear like a point when seen from in front. If we were 
then to move the convex lens from right to left, the anterior ex- 
tremity of the opacity would pass to the corresponding side, in front 
of its posterior extremity, so that the opacity would no longer 
appear like a point, but a line. The depth of opacities in the vitre- 
ous is, however, best determined by the aid of the binocular oph- 
thalmoscope. 

Opacities of the cornea are best seen with the oblique illumination, 
and appear like small gray or white spots, and their situation and 
extent can thus be ascertained with the greatest nicety. This 
method of examination will also be found useful in the detection 
and removal of foreign bodies from the cornea. In the direct mode 
of examination with the ophthalmoscope, small opacities or facets 
in the cornea lend a peculiar mottled or marbled appearance to the 
fundus, as if little dark spots or streaks are studded over its red 
expanse. We may thus also readily detect changes in the curvature 
of the cornea, and diagnose the earliest stage of conical cornea, for 
the conical portion yields a bright reflection, like a transparent 
bead or drop of water, with its base half in shadow ; the situation 
of the latter varying with the movements of the mirror. 

The appearances presented by different forms of cataract, etc., 
both by reflected and transmitted light, have already been described 
at length in the chapter upon the diseases of the lens. 

1 French Translation of Mackenzie's "Treatise on the Diseases of the Eye," p. 31. 



Chapter VII. 
DISEASES OE THE VITKEOTTS HUMOR. 



1.— INFLAMMATION OF THE VITREOUS HUMOR— 
HYALITIS. 

It was formerly supposed that the vitreous humor was incapable 
of undergoing inflammation, on account of the absence of nerves 
and bloodvessels in its structure. Thanks, however, to the re- 
searches of Virchow and Weber, it has been proved beyond doubt 
that the vitreous humor has become inflamed. Although these 
inflammatory changes generally either accompany or supervene 
upon inflammation of the deeper tunics of the eyeball, viz., the 
retina and choroid, yet many believe that idiopathic hyalitis may 
occur, and that it may be quite impossible to trace any participa- 
tion of the other tunics of the eye. Dr. Hermann Pagenstecher 
has, however, made a series of very interesting experiments upon 
rabbits, by introducing various foreign bodies into the vitreous, 
watching with the ophthalmoscope the changes thus produced, and 
finally examining the eyes microscopically. These experiments 
have led him to the opinion that the vitreous cannot undergo 
primary inflammation, but that it is always secondary and depend- 
ent on changes in the neighboring tissues. 1 

The inflammatory changes consist chiefly in a proliferation or 
hyperplasia of the cells of the vitreous humor, which become 
opaque and granular, and undergo, perhaps, fatty degeneration. 
Sometimes, there is a considerable development of connective 
tissue elements, or there may be a great tendency to suppuration, 
and large quantities of pus cells be formed. 

The progress of hyalitis is best studied by watching what 
changes occur when a foreign body (e. g., a piece of gun cap, steel, 
etc., or a displaced lens) is lodged in the vitreous humor. If the 
refracting media are sufficiently clear to permit of an ophthal- 
moscopic examination, we find that soon after the accident, the 
vitreous humor in the vicinity of the foreign body loses its trans- 
parency, and becomes somewhat hazy, which is due to the prolif- 
eration of the vitreous cells, and an increase of their nuclei and 
molecular contents. The foreign body appears to be enveloped in a 

' A brief summary of his views will be found in the " Centralblatt far medizin- 
iscben Wissenschaften," 1869, No. 43 : but a full account of the experiments, etc., 
is published in Knapp's "Archiv. for Ophthalmology and Otology," 1869, toL i. 2. 



346 DISEASES OF THE VITREOUS HUMOR. 

thin mist or cloud of bluish-gray tint, which assumes a more dense 
and firm appearance if much connective tissue is developed, and a 
creamy yellow color if suppuration sets in. The track of the 
foreign body is often visible, in the form of a thin whitish-gray 
opacity, like a thread running towards it. We sometimes find that 
these inflammatory changes in the vitreous humor, consequent 
upon the lodgment of a foreign body within it, are idiopathic, no 
trace of inflammation of the other structures of the eye being 
visible, either externally or with the ophthalmoscope. Generally, 
however, this is not the case, for symptoms of irido-cyclitis or cho- 
roiditis soon supervene, and the eye is but too frequently lost 
through suppuration. 

The simple (non-suppurative) form of hyalitis may be either acute 
or chronic, and the opacity of the vitreous be either diffused or 
circumscribed. On ophthalmoscopic examination, we may find the 
whole vitreous humor diffusely clouded, which renders the details 
of the fundus either completely invisible or very indistinct, so that 
they appear to be covered by a thin gray film or veil. In this dif- 
fuse opacity may be noticed dark, thread-like films, of varying 
size and shape, which may be either fixed, or float about when the 
eye is quickly moved. Neoplastic formations of connective tissue 
are often met with at the anterior portion of the vitreous humor, 
close to the posterior pole of the lens. They give rise to a more or 
less extensive opacity, which is sometimes termed posterior polar 
cataract. But connective tissue is also formed in other portions 
of the vitreous humor, often in very considerable quantities, giving 
rise to membranous and filamentous opacities, which, traversing 
the vitreous in different directions, may perhaps even divide it into 
fibrillar compartments. The true cellular gelatinous substance of 
the vitreous humor disappears in proportion to the development of 
the connective tissue, and generally becomes fluid (synchysis). In 
such cases the retina is often found to be extensively detached, and 
the vitreous humor shrivelled up to a very small space ; and chiefly 
consisting of connective tissue, of an almost tendinous structure, 
interspersed with loculi containing cells which have undergone 
various changes, and not unfrequently pigment molecules. 

Although simple hyalitis sometimes occurs idiopathically, yet 
generally it is dependent upon an inflammation of the retina, 
choroid, or ciliary body. 

Still more so is this the case in the suppurative form of hyalitis, 
which is but seldom idiopathic, being mostly associated with puru- 
lent iridocyclitis or irido-choroiditis, which supervenes perhaps 
upon operations for cataract, injuries, etc. As the cornea is but 
too frequently opaque, or the pupil blocked up with lymph, it is 
often impossible to trace the course of the disease with the ophthal- 
moscope. If we are, however, able to do so, we sometimes find 
that the anterior portion of the vitreous humor, close to the lens, 
yields a yellow, creamy reflex, which may be very well seen with 
the oblique illumination. It is called posterior hypopyon, and is 
due to pus iu the anterior portion of the vitreous, which may have 



OPACITIES OF THE VITREOUS HUMOR. 347 

made its way from the ciliary body or anterior segment of choroid, 
having burst through the retina. In such a case, the other por- 
tions of the vitreous may be found comparatively, or eveu com- 
pletely, healthy. In other instances, the suppuration occurs at the 
posterior or lateral portions of the vitreous, to which it may re- 
main chiefly confined, but it may also become general, and involve 
the whole of the vitreous humor. Panophthalmitis generally en- 
sues, and the globe gradually becomes atrophied, with or without 
previous perforation of the cornea or sclerotic. 

The prognosis of inflammation of the vitreous humor will de- 
pend chiefly upon the cause, and the extent to which the deeper 
tissues of the eye are implicated. I must therefore refer the reader 
for a consideration of these points, as well as the question of treat- 
ment, to the diseases of the choroid and retina. "With regard to 
the treatment, I may, however, state that in the acute cases of 
diffuse hyalitis, much benefit is often experienced from salivation, 
and the periodic application of the artificial leech to the temple. 



2— OPACITIES OP THE VITREOUS HUMOR. 

The presence of opacities in the vitreous humor is easily detected 
with the ophthalmoscope in the direct mode of examination. The 
patient should be ordered to. move his eye quickly and repeatedly 
in various directions, and then to hold it still. These movements 
will cause the opacities to be shaken up, and they will float about 
in the field of vision, and we shall thus be enabled to judge of their 
size and density, and to distinguish between the fixed and movable 
ones. When the eye is held still, the latter soon sink again to the 
lower portion of the vitreous. The excursions which these opaci- 
ties make are often very considerable, and allow us to estimate ap- 
proximately the degree of fluidity of the vitreous. The binocular 
ophthalmoscope is par